The care of a client is assigned to a newly-graduated RN. What actions can the newly-graduated RN delegate to the unlicensed assistive personnel (UAP)? [SELECT ALL THAT APPLY]
Providing oral care every 3 to 4 hours.
Help the client change position every 2 hours.
Administering 0.45% saline by IV line.
Record urine output when client voids.
Monitoring for indications of dehydration.
Assessing daily weights for trends.
Correct Answer : A,B,D
A. This task is appropriate for UAP to perform, as it involves basic hygiene and does not require nursing judgment or clinical assessment. UAP can assist with routine oral care under the direction of the RN.
B. Assisting with position changes is a basic care activity that UAP can perform. This task helps prevent pressure ulcers and maintains client comfort, and it does not require the clinical judgment of a nurse.
C. Administering IV medications or fluids is a nursing task that requires specific training and knowledge of nursing assessments, potential complications, and monitoring. This task should only be performed by a licensed nurse, not by UAP.
D. UAP can document basic measurements such as urine output, as this is a straightforward task that does not require clinical judgment. However, the RN should ensure that the UAP understands how to accurately measure and record this information.
E. While UAP can observe and report general changes, monitoring for clinical indications of dehydration requires nursing assessment skills and judgment. This task should be performed by an RN.
F. While UAP can weigh clients, the assessment of weight trends requires clinical judgment and interpretation of data, which falls under the responsibilities of a licensed nurse. The RN should evaluate and interpret the data regarding the client's health status.
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Related Questions
Correct Answer is C
Explanation
A. While monitoring temperature is important in assessing for infection, it is not the priority assessment before administering morphine. Temperature does not directly relate to the immediate effects or risks associated with opioid administration.
B. Blood pressure monitoring is essential, especially in a postoperative patient. However, opioids primarily impact the respiratory system rather than directly causing significant changes in blood pressure. While hypotension can occur with opioids, it is not the most immediate concern when administering morphine.
C. This is the priority assessment. Opioids, including morphine, can cause respiratory depression, which is a serious and potentially life-threatening side effect. Before administering morphine, it is crucial to assess the respiratory rate to ensure the patient is not at risk for respiratory distress. If the respiratory rate is low (typically less than 12 breaths per minute), the nurse may need to hold the medication and notify the healthcare provider.
D. While it is important to monitor heart rate, especially in postoperative patients, the primary concern with morphine administration is its effect on respiration. The heart rate may not be as critical to assess immediately before administering morphine as the respiratory rate is.
Correct Answer is D
Explanation
A. While prioritizing tasks is important, simply instructing the team member to focus on the most necessary tasks does not address the root of the problem. It may not provide the support or resources needed to effectively manage their workload.
B. While this might seem helpful in the short term, it does not empower the team member or address the issue of workload management. Taking on too much responsibility can also lead to burnout for the RN and is not a sustainable solution.
C. This option does not consider the needs of the original team member and may disrupt teamwork or create additional stress for other staff. It’s important to address the workload collaboratively rather than simply redistributing it without context.
D. This is the best initial action. By examining the workload together, the RN can help the team member identify which tasks are most critical and which can be deferred or delegated. This approach fosters collaboration, empowers the team member, and ensures that patient care needs are met efficiently.
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