An example of a nursing care activity that would not be delegated by an RN to a UNP is: (Select all that apply.)
Teaching self-catheterization to a patient with paraplegia who has limited English.
Basic care for a patient with a head injury who is rapidly deteriorating.
One-to-one observation with a suicidal patient.
Basic hygienic care for a patient who is post MI and stable.
Assessment of patients being admitted through the Emergency Department.
Correct Answer : A,B,E
Choice A rationale
Teaching is a complex nursing function that requires specialized knowledge, clinical judgment, and the ability to evaluate the learner's comprehension. This is especially true for a patient with a spinal cord injury and a language barrier. Self-catheterization involves sterile or clean technique and significant patient education. Delegating this to unlicensed assistive personnel is inappropriate because they lack the educational background to assess learning needs or provide the required medical instruction for invasive procedures.
Choice B rationale
The care of a patient who is rapidly deteriorating is inherently unstable and unpredictable. Nursing delegation rules strictly prohibit assigning tasks for unstable patients to unlicensed personnel because these situations require frequent, high-level clinical assessments and rapid decision-making. A head injury that is worsening could indicate rising intracranial pressure or hemorrhage, requiring the advanced skills of a registered nurse to monitor neurological status and intervene immediately. Unlicensed staff are not trained for such critical monitoring.
Choice C rationale
Providing one-to-one observation for a suicidal patient is a task that is frequently delegated to unlicensed assistive personnel or psychiatric technicians in many clinical settings. The primary goal is maintaining patient safety through constant visual contact, which does not inherently require nursing assessment or medical intervention. While the registered nurse remains responsible for the overall treatment plan and the patient's mental health assessment, the physical act of sitting with the patient is a delegable safety task.
Choice D rationale
Basic hygienic care, such as bathing or skin care, for a stable patient who has suffered a myocardial infarction is a standard task that can be safely delegated. Since the patient is noted to be stable, the risk of a sudden cardiac event during routine care is lower, and the task does not require complex clinical judgment. The unlicensed personnel can perform the ADLs while reporting any changes in the patient's comfort or skin integrity back to the RN.
Choice E rationale
Assessment is a fundamental part of the nursing process that cannot be delegated to unlicensed personnel. Admission assessments involve gathering a health history, performing a physical examination, and identifying potential nursing diagnoses. Patients entering through the Emergency Department are often undiagnosed and potentially unstable. The registered nurse must use clinical reasoning to interpret subjective and objective data to prioritize care. Unlicensed staff lack the legal scope and clinical training to perform these essential diagnostic evaluations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Documentation is an essential nursing responsibility for legal and clinical tracking, but it is never the priority over immediate physical assessment. While the nurse must eventually record the number, length, and depth of the cuts in the medical record, this occurs after the wound has been stabilized and inspected. In an emergency or acute injury situation, the nursing process mandates that assessment of the physical injury precedes the clerical task of formal medical documentation.
Choice B rationale
Administering tetanus antitoxin or a toxoid booster is a secondary consideration after the wound has been thoroughly assessed and cleaned. Tetanus prophylaxis is indicated if the patient's immunization status is unknown or outdated, especially for puncture wounds or contaminated injuries. However, the nurse must first determine the nature of the wound and the potential for contamination. Medication administration follows the initial physical assessment and wound care steps in the clinical hierarchy of nursing actions.
Choice C rationale
The first action in wound management is to inspect the injury for debris, depth, and severity. This immediate physical assessment allows the nurse to determine if there is foreign material present that could lead to infection or if the cuts require sutures. Even superficial cuts must be evaluated for the risk of secondary bacterial infection. Initial assessment is the first step of the nursing process and is vital for ensuring the physical safety of the psychiatric patient.
Choice D rationale
Implementing a behavioral modification plan is a crucial part of the long term psychiatric management of bipolar disorder and self harm behaviors. However, the nurse must prioritize the patient's immediate physiological needs before addressing the psychological or behavioral aspects. Once the physical wounds are inspected and treated, the nurse can then focus on safety protocols, such as one to one observation or behavioral contracts, to prevent further self inflicted injuries during the acute phase.
Correct Answer is B
Explanation
Choice A rationale
Leadership in nursing involves influencing others to achieve a common goal, often through the coordination of resources or the direction of a team. While the nurse showed initiative by identifying the conflict, the prompt specifically asks for the role the nurse is assuming by supporting the unit manager's plan and the provider's decisions. In this specific interaction, the nurse is acting under the guidance of the unit manager rather than directing the management of the unit.
Choice B rationale
The nurse is acting as a follower in this scenario by cooperating with the unit manager's plan. Effective followership is a skilled role where the nurse supports the leadership and the healthcare team to ensure cohesive care. By agreeing to support the provider's discussion and the manager's arrangement, the nurse ensures that the family receives a consistent message. Followership is essential in clinical settings to maintain order and implement the collective strategy for managing complex family dynamics.
Choice C rationale
Evidence based practice involves the integration of the best research evidence with clinical expertise and patient values. While the nurse's concern for the patient's wishes aligns with patient centered care, the act of supporting a manager's organizational decision is not a direct application of evidence based research. The scenario describes a behavioral and professional role within a hierarchy rather than the application of a specific clinical protocol or a research finding to a medical treatment.
Choice D rationale
Patient advocacy involves speaking up for the patient's rights and ensuring their wishes are respected. The nurse initially acted as an advocate by bringing the conflict to the manager's attention. However, the question asks for the role the nurse is playing when the manager asks them to support the provider's decisions. At that specific moment, the nurse transitions into a collaborative role within the organizational structure, following the plan laid out by the leadership.
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