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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A client who has undergone a cholecystectomy 2 days ago with decreased bowel sounds might be experiencing a common postoperative issue that requires monitoring but may not need immediate intervention. Decreased bowel sounds can result from the effects of anesthesia, pain medications, or the surgical procedure itself. While this condition warrants attention, it is not as urgent as new-onset confusion in another client.
Choice B reason: A client with diabetes mellitus and a blood glucose level of 140 mg/dL is within a manageable range, especially in a hospitalized setting. This level of blood glucose does not indicate immediate danger and can be managed with appropriate insulin or oral medication adjustments. It is important for maintaining overall glucose control, but it does not present an urgent situation requiring immediate prioritization over the other clients.
Choice C reason: A client with a left femur fracture experiencing new-onset confusion is the highest priority. New-onset confusion can be a sign of several serious conditions, such as delirium, infection, or a complication related to the fracture or its treatment. This symptom indicates an acute change in the client's condition that requires immediate assessment and intervention to determine the underlying cause and prevent further complications. Therefore, this client should be prioritized first.
Choice D reason: A client admitted for dehydration with a blood pressure of 105/77 mm Hg has a relatively stable blood pressure reading. While dehydration requires prompt treatment with fluids, this client's condition is not as critical as the client experiencing new-onset confusion. The blood pressure reading indicates that the client is maintaining an adequate circulatory status and can be managed after addressing the more urgent needs of the client with confusion.
Correct Answer is C
Explanation
Choice A reason: While this statement addresses the concern, it might come across as accusatory and could put the staff nurse on the defensive. It is important to approach the situation with a focus on problem-solving rather than blame.
Choice B reason: This statement is more of a threat and may not foster a collaborative environment. It could lead to resistance rather than cooperation. The goal should be to discuss expectations and find a solution together.
Choice C reason: This statement is constructive and sets the stage for a productive conversation. It emphasizes the need to clarify unit expectations and provides an opportunity for the staff nurse to understand and meet these expectations. It focuses on the tasks and responsibilities rather than the individual's shortcomings.
Choice D reason: This statement is likely to be perceived as judgmental and may strain the working relationship. It is important to approach the situation with empathy and a focus on resolving the issue rather than criticizing the individual.
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