The ICU nurse is assigned to provide nursing care to a client receiving mechanical ventilation. Which action should you delegate to the experienced unlicensed assistive personnel (UAP)?

Taking vital signs and pulse oximetry readings every hour.

Checking the ventilator setting to make sure they are set as prescribed.

Observing if the client's endotracheal tube needs suctioning every 2 hours.

Assessing the client's respiratory status every 4 hours.

Answer and Explanation

The Correct Answer is A

Choice A reason: Taking vital signs and pulse oximetry readings is a task that can be safely delegated to an experienced unlicensed assistive personnel (UAP). This task involves routine monitoring and does not require clinical judgment or decision-making, making it appropriate for UAPs to handle.

Choice B reason: Checking the ventilator settings requires specific knowledge about ventilator operation and adjustments. This task should be performed by a licensed nurse or respiratory therapist to ensure the settings are correct and appropriate for the client's condition.

Choice C reason: Observing if the client's endotracheal tube needs suctioning requires clinical assessment and judgment to determine the necessity and frequency of suctioning. This task should be performed by a licensed nurse who can evaluate the client's respiratory status and make appropriate decisions.

Choice D reason: Assessing the client's respiratory status involves comprehensive evaluation of the client's breathing, lung sounds, and overall respiratory function. This task requires clinical judgment and should be performed by a licensed nurse who can interpret the findings and respond appropriately.

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Correct Answer is C

Explanation

Choice A reason: Arranging for the client to remain on bedrest may not address the underlying reasons for the client's upset and agitation. While physical rest can be beneficial, it is more important to address the client's emotional and psychological needs through communication and support.

Choice B reason: Telling the client to remain calm can be perceived as dismissive and may not effectively alleviate their distress. It is important for the nurse to acknowledge the client's feelings and provide a supportive environment for them to express themselves.

Choice C reason: Encouraging the client to share their feelings is the best action to assist the client. By providing a supportive and empathetic environment, the nurse can help the client express their emotions, identify the cause of their distress, and work together to find appropriate solutions. This approach promotes therapeutic communication and can lead to a more accurate assessment and effective care plan.

Choice D reason: Giving the client time to rest and returning later for the assessment may delay addressing the client's immediate emotional needs. It is important for the nurse to engage with the client promptly to understand their concerns and provide support.

A. A nurse giving report to the oncoming shift at the client's bedside B. A nurse shredding a client's printed laboratory results C. A nurse posting positive information about a client on social media D. A nurse logging off the computer before leaving the workstation

Correct Answer is C

Explanation

Choice A reason: While giving a report to the oncoming shift at the client's bedside might potentially expose confidential information, it is generally an accepted practice in many healthcare settings as long as privacy is maintained and the patient consents.

Choice B reason: Shredding a client's printed laboratory results is actually a good practice to ensure that confidential information is disposed of securely, preventing unauthorized access.

Choice C reason: Posting any information about a client on social media, even if it is positive, is a direct breach of client confidentiality. This action exposes the client's personal health information to a wide audience, violating privacy regulations such as HIPAA.

Choice D reason: Logging off the computer before leaving the workstation is a good practice to protect client information from unauthorized access and does not represent a breach of confidentiality.

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The ICU nurse is assigned to provide nursing care to a client receiving mechanical ventilation. Which action should you delegate to the experienced unlicensed assistive personnel (UAP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a newly admitted client who appears upset and agitated. What would be the best action for the nurse to best assist this client?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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