A nurse is conducting several health assessments. Which action(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

Completing a follow-up focused assessment

Assessing a client's mental health status

Obtaining a client's vital weight

Obtaining a client's vital signs

Assessing a client's medication history

Answer and Explanation

Correct Answer : C,D

A. Completing a follow-up focused assessment: Focused assessments require nursing judgment and clinical decision-making to identify changes in a client’s condition. This task cannot be delegated to UAP because it involves interpretation of findings and determining interventions.

B. Assessing a client's mental health status: Mental health assessments require specialized knowledge and critical thinking to evaluate mood, thought processes, and risk factors. UAPs do not have the training to perform these assessments safely or interpret the results.

C. Obtaining a client's vital weight: Measuring a client’s weight is a routine, noninvasive task that does not require nursing judgment. UAPs are trained to safely obtain and record vital weights, making this appropriate to delegate.

D. Obtaining a client's vital signs: Vital signs are standard, routine measurements that UAPs can reliably perform. Nurses can delegate this task while retaining responsibility for interpreting the results and making clinical decisions.

E. Assessing a client's medication history: Gathering medication history involves evaluating prescriptions, interactions, and adherence patterns. This requires nursing knowledge and critical thinking, so it should not be delegated to UAPs.

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Correct Answer is D

Explanation

A. "It helps to determine the cost of my medications during my stay.": Medication reconciliation is not intended to evaluate cost; its purpose is focused on safety and accuracy of medication administration, not financial considerations.

B. "It is done to check if I have any allergies to the medications.": While checking for allergies is part of safe medication management, the primary goal of reconciliation is to verify all medications and prevent errors, not solely to identify allergies.

C. "It is performed to see if I need any new medications prescribed.": Although reconciliation may reveal gaps in therapy, the main purpose is to ensure consistency between pre-admission and hospital medications and to prevent errors, rather than to determine new prescriptions.

D. "It helps to reduce errors and promote safety during my stay.": This statement reflects the client’s understanding that medication reconciliation is a safety measure aimed at preventing omissions, duplications, dosing errors, or interactions, which aligns with the primary goal of the process.

A. Explain the parts of the assessment and ask permission to move forward B. Return at a later time to complete the physical assessment and interview C. Get a different nurse to complete the physical assessment and interview D. Continue with the physical assessment so the client can get treatment

Correct Answer is A

Explanation

A. Explain the parts of the assessment and ask permission to move forward: Providing a clear explanation of the assessment process and asking for consent demonstrates respect for the client’s cultural values and personal boundaries. This approach helps reduce anxiety, promotes trust, and ensures the client feels in control of their care.

B. Return at a later time to complete the physical assessment and interview: Delaying the assessment may not address the client’s immediate health needs and does not actively engage the client in reducing their apprehension. It may also prolong anxiety without providing reassurance.

C. Get a different nurse to complete the physical assessment and interview: While changing nurses might help in some cases, it does not directly address the client’s apprehension or foster communication and trust. The underlying need is for explanation and consent, not just a change in personnel.

D. Continue with the physical assessment so the client can get treatment: Proceeding without consent disregards the client’s autonomy and may increase anxiety or distrust. It could violate ethical principles and negatively impact the nurse–client relationship.

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A nurse is conducting several health assessments. Which action(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse evaluates a client's understanding of why a medication reconciliation is performed upon admission to the hospital. Which statement made by the client indicates understanding?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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