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: Battery involves harmful or offensive physical contact with another person. In this scenario, no physical contact has been made, so the UAP's actions do not constitute battery.
Choice B reason: Assault occurs when a person intentionally creates a reasonable apprehension of imminent harmful or offensive contact in another person. By threatening the client with being put in a diaper if he does not comply, the UAP is creating a fear of potential harm, which constitutes assault.
Choice C reason: False imprisonment involves the unlawful confinement of a person without their consent. While the UAP's threat is inappropriate, it does not involve actual confinement, so false imprisonment is not applicable in this situation.
Choice D reason: Invasion of privacy occurs when there is an intrusion into a person's private affairs or disclosure of private information without consent. The UAP's actions do not involve disclosing private information or intruding into the client's personal life, so invasion of privacy is not relevant here.
Correct Answer is D
Explanation
Choice A reason: A client who had open reduction and internal fixation of a femur fracture 3 days ago is likely to need ongoing monitoring and care to ensure proper healing and prevent complications. Discharging this client could risk worsening their condition or causing new issues to arise.
Choice B reason: A client admitted last night with community-acquired pneumonia is still in the early stages of treatment and may require close observation and medication adjustments to effectively manage their condition and prevent deterioration.
Choice C reason: An older adult client in the observation unit for evaluation of chest pain may still be at risk for serious conditions such as a heart attack. Releasing this client without a definitive diagnosis or proper management plan could endanger their health.
Choice D reason: A client on the medical unit for wound care for a stage 2 wound to the lower extremity is generally considered stable and appropriate for discharge, provided they have the necessary support and resources to continue wound care at home. This client does not require intensive monitoring or treatment that would necessitate hospital admission.
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