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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: The initial administration of the analgesic is not an intervention that the charge nurse should counsel the nurse about. The opioid analgesic was prescribed by the healthcare provider and was appropriate for the postoperative pain management of the client.
Choice B Reason: The decision regarding when to call the healthcare provider is an intervention that the charge nurse should counsel the nurse about. The nurse should have called the healthcare provider as soon as the client's
respiratory rate decreased to 6 breaths/minute, which is a sign of opioid-induced respiratory depression. Waiting for another 30 minutes until the respiratory rate decreased to 4 breaths/minute could have put the client at risk of hypoxia, brain damage, or death.
Choice C Reason: The documentation of the client's respiratory rate is not an intervention that the charge nurse should counsel the nurse about. The nurse documented the client's respiratory rate accurately and timely, which is part of the standard of care and legal responsibility of the nurse.
Choice D Reason: The administration of naloxone via IV is not an intervention that the charge nurse should counsel the nurse about. Naloxone is an opioid antagonist that reverses the effects of opioids and restores normal respiration. Administering naloxone via IV is the fastest and most effective way to treat opioid-induced respiratory depression.
Correct Answer is D
Explanation
Choice A Reason: Announcing the new plan at a special employee wellness event may be a good way to promote the plan and celebrate the achievement, but it is not the most important action. The nurses working on the committee should first communicate the plan to their colleagues and address any questions or concerns they may have.
Choice B Reason: Determining staff opinion of current healthcare insurance costs may be useful for evaluating the need and feasibility of the new plan, but it is not the most important action. The nurses working on the committee should have done this before developing and approving the new plan, not after.
Choice C Reason: Surveying the nurses to see who wants to keep the old benefits plan may be helpful for assessing the satisfaction and acceptance of the new plan, but it is not the most important action. The nurses working on the committee should have considered the preferences and needs of their colleagues during the development and approval of the new plan, not after.
Choice D Reason: Being available to all shifts to discuss the changes in health benefits is the most important action for the nurses working on the committee to implement, as it shows respect and transparency for their colleagues, and fosters a collaborative and supportive work environment. The nurses working on the committee should explain the rationale and benefits of the new plan, and provide feedback and guidance to their colleagues.
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