A patient in the emergency department has dyspnea, asymmetrical chest expansion, and an oxygen saturation of 90%. A chest X-ray shows a collapsed lung and blood accumulation in the pleural space.
What is the correct diagnosis?

Choice A rationale

Assessing for pain, especially using nonverbal tools, requires clinical judgment and the ability to interpret physiological and behavioral cues. This is a complex nursing skill that involves analysis and critical thinking to determine the appropriate response. Therefore, it is a task that cannot be delegated to UAP, whose scope of practice focuses on basic care and activities of daily living, not complex patient assessments or clinical judgments.

Choice B rationale

Assessing a patient's sedation needs involves evaluating their level of consciousness, response to stimuli, and other clinical indicators to determine if they are adequately sedated or if adjustments are necessary. This is a skilled nursing assessment requiring advanced knowledge of pharmacology and patient physiology. UAP are not trained to perform these assessments and cannot make the clinical judgments required for adjusting or monitoring sedation levels, making delegation unsafe and outside their scope of practice.

Choice C rationale

Obtaining consent, including permission for restraints, is a legal and ethical responsibility of the registered nurse or other licensed healthcare provider. This process involves educating the family about the risks and benefits and ensuring their understanding. It requires a detailed conversation and is beyond the scope of a UAP, who do not have the legal authority or clinical expertise to engage in discussions about informed consent for medical interventions, even non-pharmacological ones.

Choice D rationale

Providing frequent oral care is a supportive and hygienic task that is within the UAP's scope of practice. It involves performing a procedure that follows an established protocol and does not require complex clinical assessment or decision-making. Oral care is crucial for mechanically ventilated patients to prevent ventilator-associated pneumonia by reducing the bacterial load in the mouth, and it is an appropriate task for a UAP to perform under nurse supervision

Choice A rationale

Sedating the patient immediately without assessing the cause of agitation is a dangerous action. Agitation could be a sign of a serious, reversible condition such as hypoxia, a disconnected ventilator circuit, or a pneumothorax. Masking these symptoms with sedation could delay the diagnosis and treatment of a life-threatening problem. The priority is to first investigate the cause of the patient's distress to ensure their safety and provide appropriate, targeted care.

Choice B rationale

Reassuring the patient is a good practice, but it is not the most appropriate initial action. While it may help calm the patient, it does not address potential underlying physiological causes for the agitation, such as hypoxemia or a ventilator malfunction. The priority is to first perform a comprehensive physical assessment and a check of the ventilator to rule out critical, life-threatening issues before attempting to address the patient's emotional state with verbal reassurance.

Choice C rationale

Restraining the patient should be a last resort after other interventions have failed to address the cause of agitation. It can increase the patient's anxiety and is a significant safety and legal concern. Restraints can also obstruct the nurse's ability to assess the patient thoroughly and may worsen the patient's condition if the underlying cause is not identified. The priority is always to determine and treat the source of the agitation first.

Choice D rationale

Agitation in a ventilated patient is a critical sign that something is wrong, and it requires immediate investigation to determine the cause. The nurse should systematically assess the patient, starting with the ventilator circuit for disconnections or alarms, checking vital signs for hypoxia or hypotension, and auscultating lung sounds. This assessment-first approach ensures that serious, reversible causes are identified and addressed promptly, preventing harm to the patient.