The Registered Nurse makes the following request to an UAP staff: "Please get a blood sugar on the client in room 652 before 0730 this morning and report the results back to me if below 70 or above 300. Also, remember to use their left arm since they have a dialysis access in their right arm. Which of the five rights of delegation are most accurately addressed during this step in the delegation process?
Right direction
Right person
Right Supervision
Right circumstance
The Correct Answer is A
A. Right direction: The RN clearly communicates the task (obtain a blood sugar), the specific parameters for reporting results (if below 70 or above 300), and important patient-specific instructions (use the left arm due to dialysis access). This precise instruction exemplifies the right direction, ensuring the UAP understands what is expected and when to notify the RN.
B. Right person: While assigning the task to a UAP implies consideration of the appropriate staff member, the scenario does not provide details about the UAP’s competence, experience, or scope of practice. Therefore, the right person is not explicitly verified in this step.
C. Right supervision: Supervision involves the RN monitoring, evaluating, and providing guidance throughout or after task completion. In this case, the RN only instructs the UAP and specifies reporting criteria but does not describe ongoing supervision, this right is not fully addressed.
D. Right circumstance: The right circumstance involves considering patient stability, complexity of care, and context of the work environment. While the instruction accounts for a dialysis access site, the overall patient condition and risk factors are not fully addressed in this step, the right circumstance is only partially considered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Partial-thickness skin loss involving epidermis and/or dermis: Stage II pressure injuries are characterized by partial-thickness loss of skin, affecting the epidermis and possibly the superficial dermis. The wound may present as a shallow open ulcer with a red or pink wound bed, or as an intact or ruptured blister. The underlying tissue is still protected, and there is no exposure of deeper structures such as muscle, tendon, or bone.
B. Full-thickness skin loss exposing muscle or bone: This finding corresponds to Stage III or Stage IV pressure injuries. Stage III involves full-thickness skin loss with damage or necrosis of subcutaneous tissue, whereas Stage IV extends to muscle, bone, or supporting structures. Stage II wounds do not involve these deeper layers.
C. Eschar obscuring the wound bed: Eschar is necrotic tissue that can cover Stage III or IV pressure injuries, often appearing black, brown, or tan. In Stage II pressure injuries, the wound bed is typically viable and pink, without necrotic tissue obscuring visualization.
D. Intact skin with non-blanchable erythema: This is indicative of a Stage I pressure injury, where the skin remains intact but shows persistent redness or discoloration that does not blanch when pressure is applied. Stage II involves partial-thickness skin loss, which distinguishes it from Stage I.
Correct Answer is A
Explanation
A. Prolongs expiration to reduce airway resistance: Pursed-lip breathing is a technique that slows exhalation, creating back pressure in the airways. This helps prevent airway collapse, particularly in patients with obstructive pulmonary conditions such as COPD, improves alveolar ventilation, enhances gas exchange, and reduces dyspnea. Prolonged expiration also helps decrease air trapping and promotes more effective ventilation.
B. Reduces the need for PRN pain medications: Pursed-lip breathing is not intended to control pain. While relaxation and improved oxygenation may reduce anxiety or discomfort related to dyspnea, it does not have a direct analgesic effect or replace prescribed pain management strategies.
C. Uses upper chest muscles more effectively: The technique primarily focuses on controlled diaphragmatic and lip-controlled exhalation rather than emphasizing upper chest muscle activity. Overusing upper chest muscles can increase fatigue and is not the goal of this breathing technique.
D. Replaces the use of incentive spirometry: Pursed-lip breathing does not serve the same purpose as incentive spirometry, which promotes deep inhalation to prevent atelectasis. While both improve pulmonary function, pursed-lip breathing specifically targets exhalation and airway patency, not inspiratory lung expansion.
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