A registered nurse is contemplating delegating the task of administering medications to an Unlicensed Assistant Personnel (UAP). What is the primary question that the registered nurse must ask themselves before proceeding?

Is there adequate supervision available for the UAP?

Has the client’s response and approval to this task been evaluated?

Has the UAP received sufficient training to perform this task?

Does the nurse practice act and healthcare facility policy permit this delegation?

Answer and Explanation

The Correct Answer is D

Choice A rationale:
While adequate supervision is essential for safe delegation, it's not the primary question the nurse should ask. The nurse must first determine if delegation is legally and organizationally permissible.
If the nurse practice act or facility policy prohibits delegation of medication administration to UAPs, no amount of supervision can override those regulations.
Ensuring compliance with legal and professional standards is paramount to protect patient safety and the nurse's license.
Choice B rationale:
The client's response and approval are important considerations, but they don't supersede legal and organizational guidelines. If delegation isn't permitted, the client's preferences cannot justify a violation of these standards. Obtaining client consent is a crucial aspect of ethical care, but it must align with established regulations.
Choice C rationale:
UAP training is crucial for safe delegation, but it's again not the primary question.
If delegation itself isn't allowed, the UAP's level of training becomes irrelevant.
It's essential to verify the UAP's competency only after confirming the legality and organizational acceptability of delegation.
Choice D rationale:
This is the primary question because it addresses the fundamental legality and appropriateness of delegation within the specific context of the nurse's practice and workplace.

Nurse practice acts outline the scope of nursing practice and define which tasks can be delegated to unlicensed personnel.
Healthcare facility policies further delineate delegation guidelines within the institution, ensuring consistency and adherence to best practices.
By consulting these regulations first, the nurse can make an informed decision that aligns with professional standards and protects patient safety.

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Correct Answer is C

Explanation

Choice A rationale:
While elevating the head of the bed can make it easier to visualize the patient's face and upper chest, it's not the primary rationale for positioning a patient with pneumonia in semi-Fowler's position.
Skin color and temperature can be assessed in other positions as well, such as supine or side-lying. In cases of pneumonia, prioritizing respiratory function takes precedence over ease of skin assessment. Choice B rationale:
While semi-Fowler's position can offer some comfort, it's not the most comfortable position for all patients, especially those with thoracic pain.
Positions that fully support the back and minimize pressure on the chest, such as side-lying with pillows, may provide better pain relief.
The primary goal in positioning a patient with pneumonia is to optimize respiratory function, not solely to maximize comfort.
Choice C rationale:
Semi-Fowler's position effectively promotes lung expansion due to the following reasons:
Gravity: Elevating the head of the bed allows gravity to assist in pulling the diaphragm downward, creating more space for lung expansion.
Abdominal pressure: The semi-upright position reduces pressure from the abdominal organs on the diaphragm, further facilitating its downward movement and enhancing lung expansion.
Secretion drainage: The inclined position encourages drainage of secretions from the upper airways, preventing their accumulation and potential airway obstruction. This allows for better air entry and gas exchange.
Choice D rationale:
While semi-Fowler's position may slightly increase venous return to the heart, it's not the primary reason for using this position in patients with pneumonia.
Positions that significantly increase venous return, such as Trendelenburg position (head down), are typically used for specific indications like shock or hypotension, not for pneumonia management.

A. To use intra-operative data as a baseline for patient outcome comparison. B. To prevent complications from anesthesia and surgery, and to monitor and stabilize the patient they are caring for post-anesthesia. C. To focus on cardiovascular data and findings for future cases. D. To determine and report the length of time each patient recovers from anesthesia.

Correct Answer is B

Explanation

Choice A rationale:
While comparing intra-operative data to post-operative outcomes can be valuable for research and quality improvement purposes, it's not the primary purpose of immediate post-operative assessments in the PACU.
The focus in the PACU is on the patient's immediate well-being and stabilization, not on long-term data analysis.
Choice B rationale:
Preventing complications:
Early detection of potential complications is crucial for timely intervention and prevention of adverse events.
Assessments identify changes in vital signs, respiratory status, pain levels, level of consciousness, surgical site integrity, and other indicators of potential complications.
Monitoring and stabilizing the patient:
Nurses closely monitor patients' physiological responses to anesthesia and surgery, ensuring vital signs remain within acceptable ranges and managing any deviations.
They assess pain levels and administer analgesics as needed, promote respiratory function, maintain fluid and electrolyte balance, and address any other post-operative concerns.
Choice C rationale:
While cardiovascular data is indeed crucial in the PACU, it's not the sole focus of assessments.
Nurses assess a comprehensive range of body systems to ensure overall patient stability and recovery.
Choice D rationale:
Determining recovery time is important, but it's secondary to ensuring patient safety and stability.
Assessments prioritize identifying and addressing potential complications, promoting recovery, and ensuring a safe transition from the PACU.

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A registered nurse is contemplating delegating the task of administering medications to an Unlicensed Assistant Personnel (UAP). What is the primary question that the registered nurse must ask themselves before proceeding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing student is assessing a postoperative client who has developed bilateral pneumonia. The nursing plan of care includes positioning the client in the semi-Fowler’s position, elevating the head of the bed from 30 degrees to 45 degrees. What is the rationale for this position?

Correct Answer is C

Explanation

A registered nurse working in a PACU (post-anesthesia-care-unit) is responsible for conducting assessments on immediate post-operative clients. What is the purpose of these assessments?

Correct Answer is B

Explanation

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