The registered nurse (RN) is working with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) to care for a group of clients. Which nursing tasks can the RN delegate or assign? Select All That Apply.

Administering scheduled vaccinations

The bed baths and oral care

The routine oral medications for the clients

Evaluating the client's progress

Transporting a client to dialysis

Answer and Explanation

Correct Answer : A,B,C,E

Effective delegation in the healthcare setting relies on the scope of practice and the stability of the patient's condition. The RN maintains ultimate accountability for the nursing process, while assigning routine tasks to the LPN and UAP based on their specific competencies. Proper distribution of labor ensures efficiency in care delivery while maintaining strict adherence to safety standards and institutional protocols.

Rationale:

A. The administration of scheduled vaccinations is a task that can be assigned to the LPN in most clinical settings. These medications are given to stable individuals and follow a standardized protocol that does not typically require complex titration. The nurse must ensure the LPN is competent in intramuscular injection techniques before assigning the task.

B. Performing hygiene measures such as bed baths and oral care is a foundational task frequently delegated to the UAP. These activities promote patient comfort and skin integrity but do not require the advanced clinical judgment of a licensed nurse. The UAP must report any skin breakdown or abnormalities observed during the process to the RN.

C. Distributing routine oral medications is within the legal scope of the LPN, provided the patient is not in an acute crisis. The LPN is trained in pharmacology and the six rights of medication administration to ensure patient safety. The RN remains responsible for monitoring the overall therapeutic effect and any complex adverse reactions.

D. The task of evaluating a client's progress toward goals is a core component of the nursing process that cannot be delegated. Evaluation requires advanced critical thinking and the synthesis of assessment data to modify the plan of care. While the LPN and UAP provide data, the RN alone must interpret the findings.

E. Assisting with the movement and transportation of stable clients to other departments is a standard functional duty for the UAP. Transporting a client to dialysis is a routine procedure that does not require continuous clinical monitoring unless the patient's condition is hemodynamically unstable. This allows the RN to focus on higher-acuity interventions.

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Correct Answer is ["A","B","D","G"]

Explanation

Physical restraints are behavioral and safety interventions used in clients with severe agitation risk, impaired cognitive control, or danger to self/others. They require strict adherence to least restrictive measures, continuous circulatory monitoring, and frequent reassessment to prevent complications such as pressure injury, hypoxia, and psychological distress.

Rationale:

A. Clients in restraints must be placed in areas allowing continuous direct observation to prevent injury, entanglement, or circulatory compromise. This ensures rapid intervention if agitation or respiratory distress occurs. Supervision is a core safety requirement in restraint management protocols.

B. Restraints must be released at least every 2 hours to allow skin integrity assessment, range of motion, and elimination needs. This prevents neurovascular impairment, pressure injuries, and contractures. Scheduled release is a mandatory safety standard in restraint care.

C. Increasing stimulation with television may worsen sensory overload and agitation in restrained clients. This can escalate behavioral dysregulation rather than promote calming. It is not an appropriate intervention for restraint-associated anxiety management or behavioral control.

D. Soft, calming music reduces sympathetic nervous system activation and promotes relaxation in agitated clients. It supports de-escalation and decreases reliance on restraints. This is an appropriate non-pharmacologic intervention to reduce agitation and improve emotional regulation.

E. Covering tubes with gauze does not address underlying behavioral safety risk and may delay identification of complications such as dislodgement or obstruction. It is not a standard restraint alternative or safety intervention in clinical guidelines.

F. Encouraging family to leave reduces therapeutic support presence, which may worsen anxiety and agitation. Family involvement can provide reassurance and orientation. Removing support is not appropriate unless clinically indicated for safety reasons.

G. The need for continued restraints must be reassessed regularly to ensure least restrictive intervention is maintained. Ongoing evaluation prevents unnecessary restraint use and reduces risk of complications. This is a legal and ethical requirement in restraint management protocols.

A. "The procedure has a 95% success rate." B. "I will sit with and hold your hand during the procedure." C. I am going to review with you postprocedural care." D. "Do you have any questions about your procedure?"

Correct Answer is B

Explanation

The ethical principle of beneficence involves the duty to act in ways that promote the well-being of others. It requires healthcare providers to provide compassionate care and implement interventions that provide a positive benefit, balancing these actions against potential risks to ensure the client's best interest is maintained throughout the clinical encounter.

Rationale:

A. Providing statistical data regarding the success rate of a procedure is an example of providing information to support informed consent. This behavior more closely aligns with the principle of autonomy, ensuring the client has the necessary quantitative facts to make an independent decision regarding their surgical treatment.

B. Offering to provide emotional support through physical presence and touch directly demonstrates beneficence. This action aims to alleviate procedural anxiety and promote psychological comfort, representing an active effort by the nurse to do good and enhance the client's immediate emotional well-being during the surgery.

C. Reviewing postprocedural care instructions is a standard nursing requirement for patient safety and education. While helpful, this action is largely a manifestation of fidelity or the professional obligation to fulfill the nurse's role responsibilities and ensure the client is prepared for a safe recovery.

D. Asking the client if they have questions is a technique used to assess understanding and facilitate autonomous decision-making. This communication strategy supports autonomy by ensuring the client is not proceeding with the minor surgical intervention while harboring confusion or unmet information needs regarding the clinical process.

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The registered nurse (RN) is working with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) to care for a group of clients. Which nursing tasks can the RN delegate or assign? Select All That Apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse plans care for a client who requires physical restraints. Which actions should the nurse include in the plan? Select all that apply.

Correct Answer is ["A","B","D","G"]

Explanation

The nurse is caring for a client who will be having a minor surgical procedure. Which statement by the nurse to a client reflects beneficence?

Correct Answer is B

Explanation

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