The nurse can safely assign which task to an unlicensed assistive personnel (UAP) for a patient who is stable after a myocardial infarction?
Give the client his blood pressure medication
Measure the vital signs
Report any unusual lung sounds.
Teach the patient about a heart healthy diet.
The Correct Answer is B
A. Give the client his blood pressure medication: Administering medications is outside the scope of practice for UAPs and should be done by licensed nursing staff.
B. Measure the vital signs: Measuring vital signs is within the scope of practice for UAPs and can be safely assigned to them.
C. Report any unusual lung sounds: Assessing and interpreting lung sounds require the skills and training of a licensed nurse.
D. Teach the patient about a heart-healthy diet: Teaching requires assessment and evaluation, which are within the RN’s scope of practice, not the UAP’s.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "The vital signs are stable." This statement belongs in the Assessment (A) step, as it provides information about the client’s current clinical condition.
B. "The client has a history of high blood pressure." This statement belongs in the Background (B) step, providing relevant medical history.
C. "The client is disoriented. Pupils are slow to respond to light." The S (Situation) step involves stating the immediate problem or reason for the communication. Describing the client's disorientation and pupil response directly addresses the current issue that prompted the call.
D. "The client should be seen by a neurologist." This statement belongs in the Recommendation (R) step, suggesting the next course of action.
Correct Answer is C
Explanation
A. Vomiting: Vomiting is objective data because it can be observed and measured by the nurse.
B. Auscultation of heart murmur: This is objective data obtained through physical examination techniques.
C. Client's complaint of nausea: Subjective data is information reported by the client about their experience, feelings, or symptoms, which cannot be directly observed by others.
D. Blood pressure reading: This is objective data obtained through measurement.
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