A patient is on a ventilator and is sedated.
What care may the nurse delegate to the unlicensed assistive personnel (UAP)?
Use nonverbal pain assessment tools.
Assess the patient for sedation needs.
Get family permission for restraints.
Provide frequent oral care per protocol.
The Correct Answer is D
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A penetrating chest wound can lead to pneumothorax, hemothorax, or flail chest, all of which compromise the patient's ability to breathe and exchange gases effectively. The immediate and most life-threatening consequence is acute respiratory failure. Therefore, the highest priority goal is to restore adequate gas exchange to ensure proper oxygenation of the blood and removal of carbon dioxide. This goal supersedes all others.
Choice B rationale
While effective coping is important for a patient with a long-term illness or injury, it is a psychosocial goal that is not prioritized over the immediate physiological need for life support. Coping mechanisms cannot be addressed until the patient's immediate and life-threatening medical conditions, such as respiratory failure, are stabilized.
Choice C rationale
Facilitation of long-term intubation is not a primary goal of treatment; rather, it is a potential intervention to achieve the primary goal of restoring gas exchange. The ultimate goal is to wean the patient off mechanical ventilation and extubate them as soon as medically possible, not to keep them on the ventilator long-term. The intervention is a means to an end, not the end itself.
Choice D rationale
Self-management of oxygen therapy is a long-term goal that is only applicable to patients who survive the acute phase of their illness and require supplemental oxygen at home. This goal is not appropriate for a patient in acute respiratory failure in a hospital setting. The immediate priority is the stabilization of the patient and restoration of normal respiratory function, not patient education for home care
Correct Answer is C
Explanation
Choice A rationale
A patient with diarrhea may have a communicable disease, such as C. difficile or Norovirus. The patient with Stevens-Johnson syndrome has compromised skin integrity, making them highly susceptible to opportunistic infections. Placing them with a patient who has a potential infection poses a significant risk of cross-contamination and sepsis, which is a life-threatening complication for this vulnerable patient.
Choice B rationale
A patient with methicillin-resistant Staphylococcus aureus (MRSA) has a colonization or infection with a resistant bacteria. Stevens-Johnson syndrome involves extensive epidermal detachment, creating large areas of open, denuded skin, similar to a burn injury. This makes the patient extremely vulnerable to infection from resistant organisms like MRSA, which could lead to severe systemic infection and sepsis.
Choice C rationale
A patient with atrial fibrillation is not contagious and does not pose an infectious risk. Atrial fibrillation is a cardiac arrhythmia caused by an electrical conduction abnormality in the heart, with no risk of transmission. This roommate choice is the safest because it minimizes the risk of infection for the patient with Stevens-Johnson syndrome, whose compromised skin barrier makes them highly susceptible.
Choice D rationale
A fever of unknown origin (FUO) suggests an underlying infectious process that has not yet been identified. This poses a high risk of cross-contamination to the patient with Stevens-Johnson syndrome. The patient with compromised skin integrity is at an extreme risk of contracting a new infection from an undiagnosed and potentially contagious pathogen, which could lead to a severe and rapid decline in their condition.
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