The nurse is caring for clients in the intensive care unit (ICU). Which task could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

Documenting the client's fingerstick blood glucose during insulin infusion.

Monitoring vital signs during a blood transfusion.

Examining output from a client's surgically placed drain.

Obtaining the central venous pressure measurements.

Answer and Explanation

The Correct Answer is A

Choice A reason: Documenting the client's fingerstick blood glucose is a task that can be safely delegated to the UAP. This task involves recording a numeric value from a glucometer reading, which does not require clinical judgment or decision-making. UAPs are trained to perform and document such routine measurements accurately.

Choice B reason: Monitoring vital signs during a blood transfusion should not be delegated to a UAP. This task requires clinical judgment to identify and respond to potential adverse reactions, such as transfusion reactions, which is within the scope of practice for licensed nurses, not UAPs.

Choice C reason: Examining output from a client's surgically placed drain involves assessing the amount, color, and type of drainage, which requires clinical judgment to determine the significance of the findings. This task should be performed by a licensed nurse who can evaluate the client's condition and respond appropriately.

Choice D reason: Obtaining central venous pressure (CVP) measurements is a complex procedure that requires specialized knowledge and skills. It involves understanding hemodynamic monitoring and interpreting the measurements, which falls within the scope of practice for licensed nurses, not UAPs.

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Correct Answer is C

Explanation

Choice A reason: Containing the fire by closing all the doors is an important step to prevent the spread of fire and smoke, but it is not the priority action. The primary concern should be the safety of the client, which involves removing them from immediate danger.

Choice B reason: Extinguishing the fire using the nearest fire extinguisher is a critical action to control the fire, but it should not take precedence over ensuring the client's safety. The nurse must first ensure that the client is out of harm's way before attempting to put out the fire.

Choice C reason: Removing the client from immediate danger is the priority action. The nurse's first responsibility is to ensure the safety of the client by getting them to a safe area away from the fire. This action minimizes the risk of injury or harm to the client.

Choice D reason: Activating the fire alarm is essential to alert other staff and initiate emergency procedures, but it should be done after ensuring that the client is safe. The primary focus should be on the immediate safety of the client, followed by actions to manage the fire.

A. Administering tube feedings to a quadriplegic client. B. Assisting with bowel training by placing the client on the bedside commode. C. Observing the client demonstrating a self-catheterization technique. D. Teaching Crede's maneuver to a client needing to void.

Correct Answer is B

Explanation

Choice A reason: Administering tube feedings to a quadriplegic client is a task that typically requires specialized training and knowledge to ensure it is performed safely and correctly. This task is often reserved for licensed nursing personnel due to the potential complications that can arise, such as aspiration or incorrect tube placement. Therefore, it is not appropriate to delegate this task to unlicensed assistive personnel (UAP).

Choice B reason: Assisting with bowel training by placing the client on the bedside commode is an appropriate task to delegate to unlicensed assistive personnel. This task involves providing physical assistance and support to the client, which falls within the scope of practice for UAP. It does not require specialized nursing knowledge or skills, making it suitable for delegation.

Choice C reason: Observing the client demonstrating a self-catheterization technique is a task that requires clinical judgment and assessment skills to ensure the client is performing the procedure correctly and safely. This responsibility is typically within the scope of practice for licensed nurses rather than UAP.

Choice D reason: Teaching Crede's maneuver to a client needing to void involves providing instruction and education on a specific technique to assist with bladder emptying. This teaching role requires specialized knowledge and skills, making it more appropriate for licensed nursing personnel. It is not suitable for delegation to UAP.

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