The nurse cares for four clients on the medical-surgical unit. Which tasks can the nurse delegate to the unlicensed assistive personnel (UAP)? Select All That Apply.
Help a client ambulate initially after hip replacement.
Provide a client with discharge instructions.
Take vital signs on the client receiving an IV antibiotic.
Ambulate the client who is two days post-op hysterectomy
Start an IV in the client complaining of pain
Correct Answer : C,D
Effective delegation requires clinical judgment to differentiate between stable and unstable outcomes. Unlicensed personnel perform non-complex tasks involving functional activities or routine data collection. The nurse remains legally accountable for assessing patients, interpreting vital signs, and performing any invasive clinical interventions.
Rationale:
A. Postoperative patients require advanced assessment by the registered nurse during their first mobilization. Initial ambulation carries risks of orthostatic hypotension or prosthesis dislocation. The nurse must evaluate the patient's balance, weight-bearing tolerance, and neurological status before delegating subsequent walks to assistive personnel.
B. The process of discharge teaching involves complex pedagogical strategies and evaluation of learner readiness. Only the licensed nurse can provide education or clarify medical instructions. UAPs can assist with packing personal belongings but cannot explain medications, follow-up care, or signs of complications.
C. Collecting physiological data for a patient in a stable condition is a standard UAP competency. While the patient receives medication, the measurement of blood pressure and heart rate is a repetitive, objective task. The nurse must still interpret these values for potential adverse reactions.
D. Patients who are 48 hours post-hysterectomy are typically considered physiologically stable for routine activity. Assisting a recovering patient with mobility is within the UAP scope of practice once the initial assessment is complete. This helps prevent venous thromboembolism and promotes bowel motility.
E. Inserting peripheral venous catheters is an invasive procedure requiring sterile technique and clinical expertise. Such tasks are strictly outside the scope of unlicensed personnel. The nurse must perform the venipuncture and then assess the patient's response to any administered analgesic medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Neurological emergencies require rapid intervention to mitigate ischemic penumbra damage during acute cerebrovascular events. Atherosclerosis predisposes individuals to thrombotic occlusion, leading to focal deficits like dysarthria or facial drooping. Prompt evaluation is critical to assess for cortical lateralization and determine eligibility for thrombolytic therapy or mechanical thrombectomy.
Rationale:
A. Pleuritic chest pain is a classic, expected clinical finding of pericarditis inflammation that typically worsens during deep inspiration. While uncomfortable, this does not represent an immediate hemodynamic collapse or life-threatening emergency. The nurse can address this client’s pain after assessing more unstable individuals.
B. Slurred speech and drooling indicate an acute cerebrovascular accident or stroke, which is a medical emergency. These signs suggest compromised cranial nerves and a high risk for airway aspiration. This client requires the first assessment to initiate time-sensitive stroke protocols and stabilize the airway.
C. A thready pulse in mitral regurgitation suggests decreased stroke volume, but it is often a chronic manifestation of the valvular disorder. While it indicates reduced perfusion, it is less acute than a potential stroke evolving in real-time. This client is the second priority after the neurological emergency.
D. Pectus excavatum is a structural deformity of the chest wall frequently associated with connective tissue disorders like Marfan syndrome. It is a congenital finding and not an acute change requiring immediate nursing intervention or emergency stabilization. This client is the lowest priority for initial assessment.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}
Explanation
Leadership styles in nursing influence communication, decision-making, and team performance. Understanding the characteristics of each style helps nurses adapt leadership approaches to different clinical situations.
Rationale:
- Best for emergencies (Authoritarian): This style is most effective in urgent situations where quick, decisive action is needed, and the leader makes decisions without group input.
- Best for groups who are highly independent (Laissez-faire): This style works well when team members are experienced, self-directed, and require minimal supervision.
- Followers feel valued (Democratic): In this style, leaders involve team members in decision-making, which increases engagement and makes staff feel respected and valued.
- Decision process can be slow (Democratic): Because input from multiple team members is considered, decision-making takes more time.
- Minimal participation by the leader (Laissez-faire): The leader provides little direction and allows the group to function independently.
- Behavior of followers is directed (Authoritarian): The leader provides clear instructions and closely directs staff actions and responsibilities.
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