After a change of shift, you are assigned to care for the following patients.
Which patient should you assess first?

Choice A rationale

Assessing for pain and administering medications are complex nursing actions that require clinical judgment, knowledge of pharmacology, and the ability to evaluate the patient's response to treatment. These tasks fall under the legal scope of practice for a registered nurse and cannot be delegated to unlicensed personnel. UAPs lack the clinical training to perform physical assessments or determine the appropriateness of specific analgesics based on a patient's postoperative physiological status and history.

Choice B rationale

Inspection of the skin for breakdown, especially in high-risk areas like the heels following a hip replacement, is a form of physical assessment. Assessment is a core component of the nursing process that requires the advanced observational and analytical skills of a licensed nurse. While a UAP can report visible redness they notice during care, the formal, systematic evaluation of skin integrity and the determination of pressure injury risk remain the responsibility of the nurse.

Choice C rationale

Elevating a patient's heels off the bed surface is a standard preventive intervention used to reduce the risk of pressure injuries. This task is a technical, routine activity that does not require clinical judgment or complex decision-making. Since the patient is postoperative and has limited mobility, this action is appropriate for a UAP to perform as part of basic skin care and positioning, provided they have been instructed on the correct technique to maintain alignment.

Choice D rationale

Collecting vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, is a routine technical task frequently delegated to UAPs in stable patient populations. The UAP is trained to use the necessary equipment and record the numerical data accurately. However, the nurse remains responsible for interpreting these values in the context of the patient's postoperative recovery and deciding if any medical interventions are necessary based on the findings reported by the UAP.

Choice E rationale

Turning and repositioning a patient every 2 hours is a fundamental nursing assistant task aimed at preventing skin breakdown and promoting circulation. Following a hip replacement, this must be done using specific precautions, such as using an abduction pillow. A UAP can safely perform this task once they have been trained on the specific movement restrictions required for the patient's surgical procedure, helping to maintain the integrity of the musculoskeletal and integumentary systems.

Choice F rationale

Assessing for signs of deep vein thrombosis, such as redness, swelling, or warmth in the calf regions, requires clinical diagnostic skills and an understanding of postoperative complications. This is a critical assessment for a patient who has undergone major orthopedic surgery. Because it involves interpreting physical signs to identify potentially life-threatening conditions, it must be performed by the registered nurse and cannot be delegated to personnel who are not trained in clinical assessment.

Choice A rationale

Measuring intake and output is a basic data collection task that does not require nursing judgment or clinical analysis. Under the principles of delegation, a UAP can perform this task for stable patients. The RN remains responsible for analyzing the numerical data to evaluate the effectiveness of rehydration therapy. Dehydration involves fluid volume deficit where normal urine output is typically 30 mL to 60 mL per hour.

Choice B rationale

Assisting with ambulation is a standard task for UAPs and LPNs when the patient is clinically stable. Postoperative knee replacement patients require movement to prevent venous thromboembolism. If the patient is early in their recovery or unstable, the RN must perform the initial assessment. However, routine assistance with walking is appropriate for delegation as it focuses on physical support rather than complex clinical assessment of the surgical site.

Choice C rationale

Reinforcing teaching is a specific competency within the LPN scope of practice. While the RN must perform the initial education and assessment of the patient's learning needs regarding heart failure and sodium restrictions, the LPN can remind the patient of these instructions. This reinforcement helps solidify the patient's understanding of dietary triggers for fluid retention and exacerbation of heart failure symptoms, supporting the overall plan of care.

Choice D rationale

Monitoring a stable patient is within the scope of both LPNs and UAPs, depending on the specific observation required. For a patient with a history of seizures who is currently stable after a procedure, the LPN can monitor for signs of seizure activity or changes in consciousness. The RN must still perform the primary neurological assessments, but the delegation of routine observation ensures patient safety while the RN manages more complex tasks.

Choice E rationale

Administering oral medications to stable patients is a core function of the LPN. The LPN is trained to verify the five rights of medication administration and monitor for basic side effects. In a postoperative context, once the patient is stable and cleared for oral intake, the LPN can safely provide scheduled medications. The RN retains the responsibility for managing intravenous medications, blood products, and any complex titration required by the patient.

Choice F rationale

Changing a central venous catheter dressing is a sterile, complex procedure that is generally reserved for the RN in many facility policies due to the high risk of central line associated bloodstream infections. This task involves assessing the insertion site for signs of infection and maintaining strict aseptic technique. Because of the potential for significant complications and the need for advanced clinical judgment, it is not typically delegated to UAPs or LPNs.