The nurse supervisor is reviewing staff assignments made during the previous shift. Which assignment should the nurse supervisor identify as appropriate to the unlicensed assistive personnel (UAP)?

Teaching a client how to self-administer insulin.

Performing sterile wound care for a postoperative client.

Assisting a stable client with ambulation to the bathroom.

Assessing lung sounds in a client with pneumonia.

Answer and Explanation

The Correct Answer is C

Choice A reason:
Teaching clients, especially regarding medications such as insulin, requires nursing judgment, assessment of understanding, and evaluation of learning. This responsibility falls within the scope of practice of a licensed nurse, not UAP.

Choice B reason:
Sterile wound care requires clinical judgment, assessment of the wound, and evaluation for signs of infection. These tasks are outside the scope of practice for UAP and must be performed by a licensed nurse.

Choice C reason:
Assisting a stable client with ambulation is a routine, noninvasive task that does not require nursing assessment or clinical judgment. This is an appropriate delegation to UAP, provided the client is stable and mobility assistance has been deemed safe.

Choice D reason:
Assessing lung sounds involves interpretation of clinical findings and evaluation of respiratory status, which are components of nursing assessment. This task must be performed by a licensed nurse.

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Correct Answer is A

Explanation

Choice A reason:
Flushing the internal jugular central line with 0.9% normal saline ensures patency of the catheter, prevents clot formation, and maintains aseptic technique. This is a priority nursing action when receiving report to verify that the line is functional and ready for prescribed therapy.

Choice B reason:
Replacing the dressing is important for infection control but is not the first action upon receiving report. Dressing changes are typically performed at scheduled intervals or when the dressing is soiled or loose.

Choice C reason:
Administering PRN pain medication is dependent on client need and does not address the immediate assessment and safety of the central line. Ensuring line patency takes priority over routine medication administration.

Choice D reason:
Reinforcing the dressing is a supportive action but does not ensure that the line is patent. It does not address the primary safety concern of line functionality immediately after report.

A. The client has the right to be informed of any procedures they may have. B. The client has the right to leave the hospital against medical advice. C. The client has the right to refuse treatment or medication as they see fit. D. The client has the right to privacy of their health care information and records.

Correct Answer is D

Explanation

Choice A reason:
Being informed of procedures relates to the client’s right to informed consent, not directly to confidentiality. While important, it does not specifically address protection of private health information.

Choice B reason:
The right to leave against medical advice pertains to autonomy and self-determination, not confidentiality. This right ensures clients can make decisions about care but does not cover privacy of medical records.

Choice C reason:
Refusal of treatment or medication also relates to autonomy and informed consent. While ethically significant, it does not specifically address how the client’s health information is protected.

Choice D reason:
Clients have the right to privacy of their health care information and medical records, which is the core aspect of confidentiality. Teaching should include how personal health data is protected, who can access it, and how the client’s rights are maintained under HIPAA regulations and hospital policy. This ensures the client understands their legal protections and the nurse’s responsibility to safeguard their information.

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The nurse supervisor is reviewing staff assignments made during the previous shift. Which assignment should the nurse supervisor identify as appropriate to the unlicensed assistive personnel (UAP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse receives report on a client with an internal jugular access device. What action should the nurse take?

Correct Answer is A

Explanation

The nurse is teaching a client about their confidentiality rights while in the hospital as part of the admission process. Which should the nurse include in the teaching?

Correct Answer is D

Explanation

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A nurse documents the client’s vital signs and symptoms in the electronic health record before deciding on possible causes. Which phase of the nursing process is the nurse completing?

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