The practical nurse (PN) is working with the registered nurse (RN) and unlicensed assistive personnel (UAP) to care for four clients on a medical-surgical unit. Which client's care can the PN assign to the UAP?
An older adult with Alzheimer's who often wanders out of the room.
An adult postoperative client who is ready for discharge instructions.
An adolescent recently admitted with a suspected ruptured appendix.
An adult who is receiving blood and requires every 30 minute vital signs.
The Correct Answer is A
A. An older adult with Alzheimer's who often wanders out of the room: The UAP can safely monitor and assist this client with ambulation, ensuring safety and preventing falls. Tasks like observation and redirecting the client are within the UAP’s scope of practice under supervision.
B. An adult postoperative client who is ready for discharge instructions: Discharge teaching involves providing education, assessing understanding, and reinforcing care plans, which are nursing responsibilities and cannot be delegated to a UAP.
C. An adolescent recently admitted with a suspected ruptured appendix: This client requires ongoing assessment, monitoring for signs of acute deterioration, and communication of findings to the RN, which are beyond the UAP’s scope.
D. An adult who is receiving blood and requires every 30 minute vital signs: Blood transfusion monitoring is a high-risk intervention requiring assessment skills, recognition of adverse reactions, and immediate nursing intervention, so it cannot be delegated to the UAP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cleanse the finger with soap and water: Immediate cleansing of the puncture site is the first action to reduce the risk of infection or bloodborne pathogen transmission. Proper wound hygiene is critical before any further reporting or assessment steps are taken.
B. Observe the appearance of the injection site: While assessing the injection site is important, it should be done after the immediate risk of contamination has been addressed. Prioritizing wound cleansing helps prevent potential infection from the needlestick.
C. Explain the occurrence to the client: Transparency with the client is important to maintain trust, but addressing personal safety and infection risk comes first. Communication can follow once the PN has taken steps to protect themselves.
D. Call the charge nurse to the room: Reporting to the charge nurse is necessary for documentation and further management, but the PN must first perform immediate first aid on the puncture site to reduce infection risk.
Correct Answer is C
Explanation
A. Brown spots on hands and arms: These are common age-related changes (lentigines) and are not an urgent concern related to hot pack use or psoriatic care.
B. Areas of decreased pigmentation: Hypopigmentation can occur in psoriasis or with chronic skin changes, but it is not typically a sign of acute injury or complication from heat therapy.
C. Erythema and edematous areas: Redness and swelling indicate possible skin irritation or burns from hot packs. These findings require prompt referral to the charge nurse for assessment and intervention to prevent further injury or infection.
D. Yellow-white scales on the skin: These are characteristic of psoriatic plaques and are expected findings. They do not signal a complication from the heat therapy and do not require immediate referral.
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