A nurse is planning to assign care activities to nursing assistive personnel (NAP) on her team. Which of the following activities can the nurse assign to the NAP? [SELECT ALL THAT APPLY]

Accompany a client who has depression to occupational therapy.

Initiate soft wrist restraints on a client who is at risk for self-harm.

Sit with a client who has alcohol use disorder and whose last drink was five days ago.

Set limits with a client who has mania.

Work a jigsaw puzzle with a client who has dementia.

Assess a client who has hypomania for exhaustion.

Answer and Explanation

Correct Answer : A,E

A.   This is a routine task that can be safely delegated to a NAP. It does not require complex decision- making or assessment skills.
B.   This task requires the ability to assess the client's condition and determine the appropriate level of restraint. It is a task that should be performed by an RN or licensed practical nurse (LPN).
C.   While this may seem like a simple task, it requires the ability to monitor the client for signs of withdrawal and to intervene if necessary. It is a task that should be performed by an RN or LPN.
D.   This task requires the ability to assess the client's behavior and to intervene if necessary. It is a task that should be performed by an RN or LPN.
E.   This is a therapeutic activity that can be delegated to a NAP. It can help to stimulate the client's cognitive function and provide social interaction.
F.   This task requires the ability to assess the client's condition and identify potential complications. It is a task that should be performed by an RN or LPN.

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Correct Answer is C

Explanation

A. While monitoring temperature is important in assessing for infection, it is not the priority assessment before administering morphine. Temperature does not directly relate to the immediate effects or risks associated with opioid administration.
B. Blood pressure monitoring is essential, especially in a postoperative patient. However, opioids primarily impact the respiratory system rather than directly causing significant changes in blood pressure. While hypotension can occur with opioids, it is not the most immediate concern when administering morphine.
C. This is the priority assessment. Opioids, including morphine, can cause respiratory depression, which is a serious and potentially life-threatening side effect. Before administering morphine, it is crucial to assess the respiratory rate to ensure the patient is not at risk for respiratory distress. If the respiratory rate is low (typically less than 12 breaths per minute), the nurse may need to hold the medication and notify the healthcare provider.
D. While it is important to monitor heart rate, especially in postoperative patients, the primary concern with morphine administration is its effect on respiration. The heart rate may not be as critical to assess immediately before administering morphine as the respiratory rate is.

A. Disinfecting blood pressure cuffs after clients are discharged. B. Demonstrating correct hand washing to the client's visitors." C. Asking clients about the use of immunosuppressant medications. D. Screening clients for upper respiratory tract symptoms.

Correct Answer is A

Explanation

A. Disinfecting equipment is a routine infection control measure that UAPs can perform after receiving proper training on the protocol. This activity does not require clinical judgment and falls within the
UAP’s responsibilities.
B. While UAPs may assist in educating visitors about hand hygiene, the demonstration of correct hand washing techniques is typically a nursing responsibility. Nurses are trained to provide this education effectively and ensure that the information is conveyed appropriately, especially since it may involve assessing visitors’ understanding.
C. This task requires clinical judgment and assessment skills, which are within the nursing scope of practice. Nurses need to evaluate this information in the context of the client’s overall health and care plan, making it inappropriate for delegation to UAP.
D. Screening for symptoms involves assessment and interpretation, which require a nursing level of knowledge and clinical judgment. While UAPs may collect basic data or report observations, actively screening clients for specific symptoms should be performed by a nurse.

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A nurse is planning to assign care activities to nursing assistive personnel (NAP) on her team. Which of the following activities can the nurse assign to the NAP? [SELECT ALL THAT APPLY]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering this medication, the nurse should complete which priority assessment?

Correct Answer is C

Explanation

Which infection control activity should the nurse delegate to an experienced unlicensed assistive personnel (UAP)?

Correct Answer is A

Explanation

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