The nurse is caring for a postoperative patient with a hip replacement.
Which patient care actions can be delegated to the experienced unlicensed assistive personnel (UAP)? Select all that apply.
Assess for pain and administer pain medication.
Inspect the heels and other bony prominences every 8 hours.
Assure that the patient's heels are elevated off the bed.
Check vital signs and pulse oximetry saturation every 4 hours.
Turn and reposition the patient every 2 hours.
Assess the patient's calf regions for redness and swelling.
Correct Answer : C,D,E
Choice A rationale
Assessing for pain and administering medications are complex nursing actions that require clinical judgment, knowledge of pharmacology, and the ability to evaluate the patient's response to treatment. These tasks fall under the legal scope of practice for a registered nurse and cannot be delegated to unlicensed personnel. UAPs lack the clinical training to perform physical assessments or determine the appropriateness of specific analgesics based on a patient's postoperative physiological status and history.
Choice B rationale
Inspection of the skin for breakdown, especially in high-risk areas like the heels following a hip replacement, is a form of physical assessment. Assessment is a core component of the nursing process that requires the advanced observational and analytical skills of a licensed nurse. While a UAP can report visible redness they notice during care, the formal, systematic evaluation of skin integrity and the determination of pressure injury risk remain the responsibility of the nurse.
Choice C rationale
Elevating a patient's heels off the bed surface is a standard preventive intervention used to reduce the risk of pressure injuries. This task is a technical, routine activity that does not require clinical judgment or complex decision-making. Since the patient is postoperative and has limited mobility, this action is appropriate for a UAP to perform as part of basic skin care and positioning, provided they have been instructed on the correct technique to maintain alignment.
Choice D rationale
Collecting vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, is a routine technical task frequently delegated to UAPs in stable patient populations. The UAP is trained to use the necessary equipment and record the numerical data accurately. However, the nurse remains responsible for interpreting these values in the context of the patient's postoperative recovery and deciding if any medical interventions are necessary based on the findings reported by the UAP.
Choice E rationale
Turning and repositioning a patient every 2 hours is a fundamental nursing assistant task aimed at preventing skin breakdown and promoting circulation. Following a hip replacement, this must be done using specific precautions, such as using an abduction pillow. A UAP can safely perform this task once they have been trained on the specific movement restrictions required for the patient's surgical procedure, helping to maintain the integrity of the musculoskeletal and integumentary systems.
Choice F rationale
Assessing for signs of deep vein thrombosis, such as redness, swelling, or warmth in the calf regions, requires clinical diagnostic skills and an understanding of postoperative complications. This is a critical assessment for a patient who has undergone major orthopedic surgery. Because it involves interpreting physical signs to identify potentially life-threatening conditions, it must be performed by the registered nurse and cannot be delegated to personnel who are not trained in clinical assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Notifying the provider of noncompliance is medically inaccurate and clinically inappropriate in this context. The patient is not choosing to be noncompliant but is instead facing significant socioeconomic barriers including food insecurity and lack of refrigeration. Labeling a patient as noncompliant fails to address the underlying social determinants of health. Nurses must identify these external stressors to provide equitable care rather than attributing systemic poverty to a personal failure of the patient.
Choice B rationale
Medication management must be tailored to the patient's environment to ensure safety and efficacy. Many insulin formulations require refrigeration for long term stability, which is impossible for this patient. Exploring alternatives like oral glucose lowering agents or medications with longer room temperature stability prevents drug degradation. Addressing the lack of a refrigerator is a direct intervention for a social determinant of health that impacts the biochemical management of type 2 diabetes and prevents hypoglycemia.
Choice C rationale
Transportation is a major social determinant of health that directly impacts clinical outcomes and patient safety. Without reliable transport, the patient cannot attend follow up appointments for hemoglobin A1c monitoring, which should remain below 7 percent. Lack of access to healthcare facilities leads to poorly managed blood glucose levels and increased risk for chronic complications like nephropathy or retinopathy. Assessing this need allows the nurse to coordinate with community resources to ensure continuity of care.
Choice D rationale
Social services play a critical role in addressing food insecurity, which is a primary social determinant of health. Food insecurity leads to unpredictable caloric intake, making it dangerous to administer medications like sulfonylureas that can cause severe hypoglycemia. Referrals to assistance programs ensure the patient has access to consistent nutrition. Stabilizing food access allows for a predictable dietary pattern, which is essential for maintaining blood glucose levels within the target range of 70 to 130 mg/dL.
Choice E rationale
Reinforcing a diet without considering the patient's financial circumstances is an ineffective and dismissive nursing action. It ignores the reality of the patient's situation and fails to provide a realistic plan for health promotion. Quality care requires the nurse to adapt education to the patient's specific socioeconomic status. Simply repeating instructions that the patient has already stated they cannot follow does not improve safety and ignores the barriers identified during the initial nursing assessment.
Correct Answer is A
Explanation
Choice A rationale
Malpractice is defined as professional negligence that occurs when a person with specialized education and licensing fails to act as a reasonably prudent professional would in a similar situation. It requires the presence of a duty, a breach of that duty, causation, and resulting damages or injury. In nursing, this means failing to meet the standard of care expected of a registered nurse, leading to patient harm. This definition distinguishes it from general negligence.
Choice B rationale
Sharing information that damages a patient's reputation is legally classified as defamation, specifically libel if written or slander if spoken. While this is a violation of professional ethics and patient confidentiality, it is an intentional tort rather than the unintentional tort of malpractice. Malpractice specifically concerns the delivery of clinical care and the failure to perform professional duties safely. Therefore, damaging a reputation through speech does not meet the scientific legal definition of malpractice.
Choice C rationale
Malpractice is a civil wrong, or a tort, rather than a criminal offense. Criminal offenses are prosecuted by the state and can lead to imprisonment, whereas malpractice suits are private civil actions intended to provide financial compensation for losses. While a healthcare provider's actions could theoretically lead to criminal charges like manslaughter in extreme cases, the legal concept of malpractice itself is handled in civil court. It does not carry the label of a crime.
Choice D rationale
Malpractice is never considered a minor criminal offense because it is not part of the criminal justice system at all. It is a civil matter. Additionally, the impact of malpractice can be devastating, leading to permanent disability or death, which contradicts the idea of it being minor. In the legal hierarchy, it is a significant civil liability that can result in the loss of professional licensure and substantial monetary judgments, emphasizing its seriousness in healthcare.
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