A nurse who works in a long-term care facility is delegating aspects of client care to unlicensed assistive personnel (UAP). Which assignment(s) should the nurse delegate? (Select all that apply.)

Identify locations of skin lesions on a newly admitted client.

Empty the ostomy bag for a client with a temporary colostomy.

Provide a complete bed bath for a comatose client.

Perform foot care including toenail trimming and heel care.

Give mouth care to an elderly client who has a tracheostomy.

Answer and Explanation

Correct Answer : B,C

Choice A Reason: Identifying locations of skin lesions on a newly admitted client is a nursing assessment that requires clinical judgment and cannot be delegated to the UAP.

Choice B Reason: Emptying the ostomy bag for a client with a temporary colostomy is a routine task that does not require clinical judgment and can be delegated to the UAP.

Choice C Reason: Providing a complete bed bath for a comatose client is a routine task that does not require clinical judgment and can be delegated to the UAP.

Choice D Reason: Performing foot care including toenail trimming and heel care is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP. The UAP may cause injury or infection to the client's feet, especially if the client has diabetes or peripheral vascular disease.

Choice E Reason: Giving mouth care to an elderly client who has a tracheostomy is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP. The UAP may cause trauma or aspiration to the client's trachea, especially if the client has poor oral hygiene or respiratory secretions.

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Correct Answer is A

Explanation

Choice A Reason: Influenza is transmitted primarily through respiratory droplets. Droplet precautions require healthcare workers to wear a mask (surgical mask) when in close contact with a client. The UAP is already wearing gloves and a gown, which are appropriate for contact precautions but incomplete without a face mask for droplet protection.

Choice B Reason: A fitted respirator (e.g., N95) is unnecessary unless the client is suspected or confirmed to have an airborne transmissible disease such as tuberculosis. Influenza does not require airborne precautions.

Choice C Reason: Assigning the UAP to provide care for another client and assuming full care of the client is not necessary or feasible because it would increase the workload of the nurse and reduce the quality of care for both clients. The UAP can still assist with care for clients with influenza as long as they follow proper infection control measures.

Choice D Reason: Instructing the UAP to notify the nurse of any changes in the client's respiratory status is important but not a priority action because it does not address the issue of preventing transmission of influenza. The nurse should first ensure that the UAP wears appropriate personal protective equipment before entering the client's room.

A. The brain natriuretic peptide (BNP) assay for a client with shortness of breath after a myocardial infarction (MI) increases to 1000 pg/mL (1000 ng/L). B. The international normalized ratio (INR) for a client who is receiving warfarin therapy increases to 2.5. C. The serum glucose level for a client receiving corticosteroids increases to 150 mg/dL (8.3 mmol/L). D. The potassium level for a client scheduled for renal dialysis increases to 5 mEq/L(5 mmol/L).

Correct Answer is A

Explanation

Choice A Reason: This client has a very high BNP level, which indicates severe heart failure and fluid overload. The nurse should follow up with this client first, as they may need urgent interventions such as oxygen therapy, diuretics, and vasodilators.

Choice B Reason: This client has an INR within the therapeutic range for warfarin therapy, which is usually between 2 and 3. The nurse should monitor this client for signs of bleeding or clotting, but they do not require immediate follow-up.

Choice C Reason: This client has a mildly elevated glucose level, which may be caused by the corticosteroids that

increase blood sugar. The nurse should check the client's blood glucose regularly and administer insulin as ordered, but they do not require immediate follow-up.

Choice D Reason: This client has a normal potassium level, which is within the reference range of 3.5 to 5 mEq/L. The nurse should ensure that the client is ready for dialysis and avoid foods high in potassium, but they do not require immediate follow-up.

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A nurse who works in a long-term care facility is delegating aspects of client care to unlicensed assistive personnel (UAP). Which assignment(s) should the nurse delegate? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A client with influenza is admitted to the medical unit. The nurse observes an unlicensed assistive personnel (UAP) preparing to enter the client's room to take vital signs and assist with personal care. The UAP has applied gloves and a gown. Which action should the nurse take?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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