The nurse is having an exceptionally busy shift on an obstetrical unit.
Which of the following tasks is the nurse justified in delegating to an unlicensed care provider?
Emptying a client's Foley catheter bag and reporting the volume to the nurse.
Helping a first-time mother achieve a good latch when breastfeeding her infant.
Assessing the size and quantity of clots that are in a client's bedpan and informing the nurse.
Giving an anti-inflammatory medication to a client who is eight hours postdelivery.
The Correct Answer is A
Choice A rationale
Emptying a Foley catheter bag and reporting the urine volume is a routine task that does not require complex assessment or clinical judgment. Unlicensed care providers are typically trained in this procedure and can accurately measure and report the output to the nurse.
Choice B rationale
Helping a first-time mother achieve a good latch during breastfeeding requires specialized knowledge and assessment skills to ensure proper positioning and infant feeding. This task involves teaching and evaluating, which falls within the scope of nursing practice and should not be delegated to an unlicensed care provider.
Choice C rationale
Assessing the size and quantity of blood clots in a postpartum client's bedpan requires clinical judgment to determine if the findings are within normal limits or indicative of a potential complication. This assessment should be performed by a registered nurse who can interpret the findings in the context of the client's overall condition.
Choice D rationale
Administering medication, including anti-inflammatory drugs, is a nursing responsibility that requires knowledge of pharmacology, potential side effects, and client assessment. Medication administration should not be delegated to unlicensed care providers. .
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Identifying factors that interfere with normal sleep patterns is a crucial step in addressing sleep disturbances, but it doesn't directly demonstrate the effectiveness of a plan of care to promote rest and sleep. While understanding these factors can lead to interventions, the actual outcome is reflected in the improvement of sleep quality.
Choice B rationale
Verbalizing an ability to sleep without medications is a positive outcome, but it doesn't solely indicate the effectiveness of a comprehensive plan of care. The quality and duration of sleep are also critical indicators of successful interventions aimed at promoting rest and sleep, beyond just medication independence.
Choice C rationale
Engaging in relaxing activities before bedtime is a helpful strategy to promote sleep, but it is an action taken by the patient, not a direct measure of the plan's effectiveness. The ultimate success of the plan is determined by whether these activities actually result in improved rest and sleep.
Choice D rationale
Reporting improved quality of rest and sleep directly indicates that the plan of care has been effective in achieving its goal. This subjective measure, when consistently reported by the patient, signifies that the interventions implemented have positively impacted their ability to rest and sleep well.
Correct Answer is D
Explanation
Choice A rationale
Impaired Skin Integrity involves damage to the epidermal and/or dermal layers of the skin. While excessive fluid loss can indirectly affect skin turgor and increase the risk of breakdown over time, the primary and immediate physiological consequence of increased urinary output due to a diuretic is a potential reduction in overall fluid volume within the body, not a direct impairment of skin integrity.
Choice B rationale
Impaired Urinary Elimination describes difficulties in controlling or completely emptying the bladder. A diuretic, by its mechanism of action, increases urine production and thus promotes urinary elimination. While the *pattern* of elimination may change (increased frequency, urgency), the fundamental issue is not an impairment of the elimination process itself but rather an *increase* in it.
Choice C rationale
Urinary Retention is the inability to empty the bladder completely. A diuretic works to increase urine output, directly counteracting the physiological process of urinary retention. Therefore, this nursing diagnosis would be inappropriate for a client experiencing increased urinary output due to diuretic use.
Choice D rationale
Risk for Deficient Fluid Volume is a nursing diagnosis that identifies a vulnerability to a decrease in intravascular, interstitial, and/or intracellular fluid, which may compromise health. A diuretic increases urinary output, leading to a greater loss of fluid from the body. Without adequate fluid intake to compensate for this increased loss, the client is at a significant risk of developing a fluid volume deficit.
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