The LPN in a long-term care facility is considering her tasks for the day. When delegating to the UAP (unlicensed assistive personnel), which of the following statements provide the UAP with the essential goal to communicate the assignment?
The client in bed number 1 is weak, so help her ambulate so she does not fall.
Document vital signs every 4 hours today for your assigned patients who need vital signs.
Encourage frequent position changes to reduce pressure injury.
Please check the blood pressure for Mrs. Brown in room number 2 and report back by 7:30 AM.
Correct Answer : A,D
Choice A reason: This statement is appropriate because it clearly communicates the client’s condition (weakness) and the specific task (assist with ambulation to prevent falls). It provides the UAP with a clear purpose and safety goal. Preventing falls is a major priority in long-term care facilities, and UAPs are trained to assist with ambulation under supervision. The instruction is measurable and actionable, making it a safe and effective delegation.
Choice B reason: This statement is not appropriate because documenting vital signs is outside the scope of practice for a UAP. While UAPs can measure and record vital signs, the responsibility for documentation in the medical record belongs to licensed staff. Delegating documentation to a UAP risks inaccurate charting and violates professional standards. Therefore, this does not effectively communicate an appropriate assignment.
Choice C reason: This statement is incomplete and vague. While encouraging position changes is within the UAP’s scope, the instruction lacks specificity about frequency, timing, or which patients require repositioning. Effective delegation requires clear, measurable instructions. Without these details, the UAP may not understand the priority or urgency, making this statement insufficient for safe delegation.
Choice D reason: This statement is appropriate because it specifies the patient (Mrs. Brown), the task (check blood pressure), and the time frame (report back by 7:30 AM). It provides a clear, measurable assignment that is within the UAP’s scope of practice. UAPs are trained to measure vital signs and report findings to licensed staff. This instruction ensures accountability and timely communication, which supports safe patient care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The “S” in ISBAR stands for Situation, which describes the immediate problem or concern. Reporting new onset dyspnea and chest pain directly communicates the urgent situation requiring physician attention.
Choice B reason: A history of heart failure belongs in the “Background” section of ISBAR, not the situation. Background provides context but does not describe the current issue.
Choice C reason: Stating that the patient will be sent to the ED is part of “Recommendation,” not situation. Recommendation outlines the next steps or requests.
Choice D reason: Reporting that the patient is alert and oriented is part of “Assessment,” not situation. Assessment describes the patient’s current status after evaluation.
Correct Answer is D
Explanation
Choice A reason: Checking for a carotid pulse for one full minute is inappropriate in an emergency because it delays initiation of CPR. Pulse checks should be brief to avoid wasting critical time.
Choice B reason: Checking an apical pulse for 30 seconds is not appropriate in an unresponsive patient. Apical pulse assessment is used for routine monitoring, not emergency situations.
Choice C reason: Counting the radial pulse for one full minute is inappropriate because radial pulses may be absent in cardiac arrest, and this delays life-saving interventions.
Choice D reason: This is the correct action because in an unresponsive patient, the nurse should check for a carotid pulse for no longer than 10 seconds. If no pulse is detected, CPR should be initiated immediately. This aligns with current resuscitation guidelines, which emphasize minimizing delays in chest compressions.
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