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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Fidelity refers to the ethical principle of keeping promises and maintaining trust. In nursing, this principle involves being loyal to the client and upholding commitments made to them. While important, fidelity does not directly address the nurse's concern about the potential harm caused by administering the opioid medication.
Choice B reason: Nonmaleficence is the ethical principle of "do no harm." This principle is directly applicable in this scenario, as the nurse's concern is about potentially hastening the client's death by administering the opioid medication. By choosing not to administer the medication, the nurse is acting to avoid causing harm, aligning with the principle of nonmaleficence.
Choice C reason: Veracity is the principle of truthfulness and honesty. It involves providing accurate information to clients and being truthful in communication. Although important in healthcare, veracity does not specifically address the nurse's concern about the potential harm of administering the opioid medication.
Choice D reason: Utilitarianism is an ethical theory that focuses on the consequences of actions and aims to achieve the greatest good for the greatest number of people. While utilitarianism can guide decision-making in healthcare, it is not the most relevant principle in this scenario where the primary concern is avoiding harm to the individual client.
Correct Answer is D
Explanation
Choice A reason: Incident reports are internal documents used within the hospital to record and analyze adverse events. They are not intended for direct reporting to state, local, and federal agencies, which have their own reporting mechanisms.
Choice B reason: While incident reports may indirectly contribute to assessing the effectiveness of interventions, their primary purpose is not to determine outcomes. Instead, they focus on documenting and analyzing incidents to prevent future occurrences.
Choice C reason: Providing necessary treatment to clients is the immediate response to an incident. However, the purpose of the incident report is broader—it aims to capture the details of the event for analysis and future prevention, not directly to ensure treatment.
Choice D reason: The primary purpose of an incident report is to help the institution identify risk situations and improve client care. By systematically documenting incidents, the hospital can analyze patterns, identify areas for improvement, and implement strategies to enhance safety and quality of care.
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