There is one client on a mechanical soft diet who needs help with food tray set-up. A second client received pain medication 30 minutes ago, is a fall risk, and requires ambulation assistance to the bathroom. Which task is priority for the Registered Nurse and which task could be delegated to the UAP?
The nurse should not delegate either task to the UAP and should ambulate the recently medicated client by themselves.
The nurse should delegate both tasks to the UAP and ask that the UAP to start with the recently medicated client.
The nurse should ambulate the recently medicated client and the UAP assist with tray set-up.
The nurse should assist with tray set-up and the UAP ambulate the recently medicated client.
The Correct Answer is C
A. The nurse should not delegate either task to the UAP and should ambulate the recently medicated client by themselves: While the nurse must retain accountability for high-risk activities, delegating low-risk tasks such as tray set-up to a UAP is safe. Avoiding delegation entirely is inefficient and not necessary if proper supervision and scope of practice are followed.
B. The nurse should delegate both tasks to the UAP and ask that the UAP start with the recently medicated client: Ambulating a client who has received pain medication 30 minutes ago and is a fall risk requires nursing judgment and assessment of stability. This task is unsafe to delegate to a UAP and could result in falls or injury, making this inappropriate.
C. The nurse should ambulate the recently medicated client and the UAP assist with tray set-up: Ambulating a high-risk client requires the nurse’s clinical judgment, timing, and direct intervention for safety. Assisting a client with a mechanical soft diet is a routine, low-risk task appropriate for a UAP. This prioritizes patient safety while effectively delegating suitable tasks.
D. The nurse should assist with tray set-up and the UAP ambulate the recently medicated client: Delegating ambulation of a recently medicated, fall-risk client to a UAP is unsafe because it requires professional assessment of mobility and the potential effects of analgesics on balance and alertness. This compromises patient safety and is not within the UAP’s scope of practice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Encourage the client to research the procedure online: While providing additional information can be helpful, asking a client to research a complex surgical procedure online may expose them to inaccurate or misleading information. It also does not address the immediate barrier to comprehension during the consent discussion.
B. Provide the client with a pamphlet of the procedures: Pamphlets can supplement understanding, but they are often written at a reading level that may still be difficult for some clients. They are insufficient on their own to ensure informed consent if the client is struggling to follow the real-time conversation and requires verbal clarification.
C. Ask the surgeon to slow the pace and avoid medical jargon: This action directly addresses the client’s difficulty understanding the procedure. Simplifying language, using lay terms, and slowing the explanation ensures the client can comprehend the information necessary to give informed consent. It reflects advocacy for patient comprehension and supports ethical and legal standards in the consent process.
D. Ask the surgeon to repeat the explanation over again: Simply repeating the explanation at the same pace using the same terminology may not improve understanding. Without adjusting the language or providing clarification, the client may remain confused, and informed consent may still not be achieved.
Correct Answer is A
Explanation
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.
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