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The Emergency Department nurse is admitting a 58-year-old client with atypical chest pain. Which actions would the nurse delegate to the experienced unlicensed assistive personnel? Select All That Apply.

Check admission vital signs and record.

Assess the client's level of chest pain.

Assist the client in using the bathroom.

Label and place the client's belongings in a plastic bag.

Complete a 12-lead ECG for the client.

Place the client on a continuous cardiac monitor.

insert a saline lock and draw blood samples for the lab.

Answer and Explanation

Correct Answer : A,C,D

Delegation to unlicensed assistive personnel involves assigning noninvasive tasks, routine data collection, and basic activities of daily living. Tasks requiring clinical judgment or sterile procedures remain the nurse’s responsibility to ensure safety in acute cardiac presentations.

Rationale:

A. Checking and recording admission vital signs is appropriate for UAP as it is a routine, noninvasive task. It does not require interpretation. This supports data collection and allows the nurse to analyze findings and determine clinical significance.

B. Assessing chest pain requires clinical judgment, including evaluating intensity, quality, and associated symptoms. This cannot be delegated. It involves nursing assessment and critical clinical interpretation, which must be performed by a licensed nurse.

C. Assisting the client to the bathroom is a basic activity of daily living suitable for UAP delegation. It does not involve clinical decision-making. This promotes patient comfort and maintains mobility support safely under supervision.

D. Labeling and securing client belongings is a nonclinical task appropriate for UAP. It ensures organization and prevents loss of personal items. This supports environmental management and maintains client property safety during admission.

E. Completing a 12-lead ECG requires proper lead placement and technical skill, often performed by trained technicians or nurses. It is not a basic UAP task. This involves technical competency and impacts diagnostic accuracy.

F. Placing a client on a continuous cardiac monitor requires knowledge of lead placement and interpretation readiness. It is not delegated to UAP. This involves cardiac monitoring setup and requires clinical oversight.

G. Inserting a saline lock and drawing blood are invasive procedures requiring sterile technique and clinical training. These tasks cannot be delegated to UAP. This involves invasive procedures and risk of infection or complications.

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Correct Answer is D

Explanation

Evidence-based practice (EBP) relies on the hierarchical synthesis of clinical research to validate procedural changes and improve patient outcomes. Systematic reviews and meta-analyses occupy the highest levels of the evidence pyramid, providing a rigorous evaluation of multiple studies. This approach minimizes sampling bias and ensures that nursing interventions are grounded in statistically significant, reproducible scientific data.

Rationale:

A. Ambiguous statistics indicate a lack of statistical significance or clarity in the research findings, making the data unreliable for clinical application. Evidence used to change hospital policy must demonstrate internal validity and clear, consistent results to ensure patient safety. Articles with vague or conflicting data cannot justify a shift in standardized protocols.

B. Research conducted by the manufacturer presents a significant conflict of interest, which can compromise the objectivity of the study results. Independent, peer-reviewed research is necessary to eliminate commercial bias and ensure the product’s efficacy is evaluated neutrally. Trustworthy EBP requires findings that are free from financial influence or industry-driven motives.

C. A study with only 10 subjects has an inadequate sample size, which severely limits the generalizability of the findings to a broader population. Small cohorts lack the statistical power required to prove that results are not due to mere chance. For central line care, robust data from large, multi-center trials are essential to mitigate clinical risks.

D. A review-of-literature that synthesizes numerous studies represents a systematic approach to evidence, offering the strongest support for a new procedure. These articles aggregate diverse data points to confirm the clinical efficacy and safety of a product across various settings. This high-level evidence provides the necessary scientific justification for modifying nursing practice and improving infection control.

A. Assess the client to rule out any complications secondary to the client's pain. B. Administer intravenous sodium bicarbonate to the client. C. Determine the last time the client was medicated for abdominal pain. D. Check the amount of suction on the client's nasogastric tube.

Correct Answer is D

Explanation

Metabolic alkalosis results from the excessive loss of gastric hydrochloric acid during prolonged nasogastric suctioning or emesis. This depletion of hydrogen ions causes a rise in serum pH and an accumulation of bicarbonate ions, shifting the acid-base balance toward alkalinity. Compensatory mechanisms include hypoventilation to retain carbon dioxide, though this is often limited by the body’s physiological requirement for oxygenation.

Rationale:

A. While assessing for complications of pain is a standard nursing responsibility, the objective data indicates a primary metabolic imbalance that must be addressed at its source. Pain typically causes respiratory alkalosis via hyperventilation, but this client's PaCO2 is within normal limits, suggesting the pain is not the cause of the pH shift. Clinical priority must remain on the most likely cause of the alkalotic state.

B. Administering intravenous sodium bicarbonate is strictly contraindicated as it would further elevate the pH and worsen the metabolic alkalosis. Sodium bicarbonate is used to treat metabolic acidosis, and its administration in this scenario could lead to severe tetany or cardiac arrhythmias. The nurse must recognize that the client already has an excess of base bicarbonate in their system.

C. Medicating the client for pain is an important comfort measure, but the priority is to stop the pathological loss of electrolytes and acid. A heart rate of 103 bpm with a new U wave is a classic sign of hypokalemia, which frequently accompanies metabolic alkalosis from gastric suctioning. Determining the last dose of analgesia does not address the imminent cardiac risk associated with electrolyte depletion.

D. Checking the suction level is the first action to prevent further gastric acid depletion and stabilize the metabolic state. Excessive or continuous suctioning is the direct cause of the elevated pH and bicarbonate levels seen in this client’s ABG report. Adjusting the suction to the prescribed intermittent or low setting is the primary intervention to halt the hydrochloric acid loss.

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The Emergency Department nurse is admitting a 58-year-old client with atypical chest pain. Which actions would the nurse delegate to the experienced unlicensed assistive personnel? Select All That Apply.

Nursing Test Bank

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