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 B
Explanation
Choice A rationale
Contact dermatitis is an inflammatory reaction of the skin caused by contact with an irritant or allergen. Avoiding hot showers and baths is a correct teaching point, as heat can exacerbate itching and further irritate the skin barrier, leading to increased inflammation and discomfort. This statement shows correct understanding.
Choice B rationale
Contact dermatitis is not contagious. The rash is a localized inflammatory response and cannot be spread from person to person. A statement about isolating oneself indicates a significant misunderstanding of the condition's etiology and transmission. This is the statement that requires further education from the nurse.
Choice C rationale
Applying unscented moisturizer is a correct and helpful intervention for contact dermatitis. Moisturizers help to restore the skin's barrier function, reduce dryness and scaling, and can soothe the irritated area. Using an unscented product is important to avoid further irritation from potential allergens in fragrances.
Choice D rationale
Maintaining adequate hydration is beneficial for overall skin health and can support the skin's healing process. While 100 oz may be a large amount for some, drinking adequate fluids is generally a sound recommendation for promoting skin barrier function and systemic health during an inflammatory process. .
Correct Answer is C
Explanation
Choice A rationale
Antibiotics are ineffective against shingles because the disease is caused by a virus, not bacteria. Shingles, or herpes zoster, is a reactivation of the varicella-zoster virus. Antibiotics target and kill bacteria by disrupting their cell walls or inhibiting protein synthesis. Administering an antibiotic would not address the viral cause of the disease and would not reduce the pain or halt its progression.
Choice B rationale
Antifungal medications are not indicated for the treatment of shingles. These drugs are specifically designed to treat infections caused by fungi by targeting the fungal cell wall or membrane. Since shingles is a viral infection, antifungal drugs would have no therapeutic effect on the varicella-zoster virus and would fail to alleviate symptoms or alter the course of the disease.
Choice C rationale
Antiviral medications are the primary treatment for shingles. These drugs, such as acyclovir, valacyclovir, and famciclovir, work by inhibiting viral DNA replication. By interrupting the viral life cycle, they can reduce the severity and duration of the outbreak, lessen the associated pain, and decrease the risk of postherpetic neuralgia. These medications are most effective when initiated within 72 hours of symptom onset.
Choice D rationale
While anti-inflammatory medications may be used to manage the pain associated with shingles, they do not halt the progression of the disease. Nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids can reduce inflammation and provide symptomatic pain relief. However, they do not target the varicella-zoster virus itself. The primary treatment to stop the viral replication and disease progression is an antiviral medication. *.
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