Which instruction would the nurse give when instructing the UAP (unlicensed assistive personnel) to give a complete bed bath to a patient?

Use 1 washcloth for the whole body.

Do not massage any reddened areas on the patient’s skin.

Disconnect the IV tubing when changing the patient’s gown.

Be sure to wash the patient’s face with soap.

Answer and Explanation

The Correct Answer is B

Choice A reason: This instruction is inappropriate because using one washcloth for the entire body increases the risk of cross-contamination and infection. Different washcloths should be used for different areas, especially the face and perineal region, to maintain hygiene and prevent spread of microorganisms.

Choice B reason: This is the correct instruction because massaging reddened areas can worsen tissue damage and increase the risk of pressure injuries. UAPs should be taught to avoid massaging compromised skin and instead report any findings to the nurse. This demonstrates safe and evidence-based practice.

Choice C reason: This instruction is unsafe because UAPs should not disconnect IV tubing. Handling IV lines requires nursing knowledge and skill to prevent infection, dislodgement, or medication errors. This task is outside the UAP’s scope of practice.

Choice D reason: This instruction is incorrect because the patient’s face should be washed with plain water, not soap, to avoid irritation of sensitive facial skin. Soap can cause dryness or discomfort.

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Correct Answer is D

Explanation

Choice A reason: Removing restraints every 15 minutes is excessive and impractical. While frequent monitoring is required, removing restraints this often could compromise patient safety if the restraints are necessary to prevent harm. Toileting should be offered regularly, but the removal schedule must balance patient dignity with safety.

Choice B reason: Checking restraints every 2 hours is insufficient. Patients in restraints must be monitored much more frequently to ensure circulation, skin integrity, and safety. Two-hour intervals could allow complications such as impaired circulation, skin breakdown, or psychological distress to go unnoticed.

Choice C reason: Delegating safety checks to a UAP every hour is inappropriate because restraint monitoring requires licensed nursing judgment. LPNs must personally assess circulation, skin condition, and patient comfort. UAPs can assist with care but cannot replace the nurse’s responsibility for restraint monitoring.

Choice D reason: The correct action is to check the patient every 15 minutes and remove restraints every 2 hours if safe. This schedule ensures frequent monitoring for circulation, skin integrity, and psychological well-being, while also providing opportunities for mobility, toileting, and comfort. Removing restraints every 2 hours prevents complications and respects patient dignity, while frequent checks ensure safety.

A. The LPN takes vital signs on the client and then administers the red blood cells B. The LPN tells the doctor, “That is outside my scope of practice; you will have to find someone else.” C. The LPN delegates the vital signs to the nurse’s aide while she administers the red blood cells D. The LPN takes the vital signs on the client and asks the charge RN to administer the red blood cells

Correct Answer is D

Explanation

Choice A reason: Administering PRBCs is outside the scope of practice for LPNs in most jurisdictions. Blood transfusions require RN-level training and monitoring due to the risk of severe transfusion reactions.

Choice B reason: While it is correct that administering PRBCs is outside the LPN’s scope, simply refusing without ensuring patient safety is not appropriate. The LPN must escalate the order to the RN or charge nurse to ensure the patient receives timely care.

Choice C reason: Delegating vital signs to a nurse’s aide while administering PRBCs is unsafe and outside the LPN’s scope. The LPN cannot administer blood products, and vital signs during transfusion must be closely monitored by a licensed nurse.

Choice D reason: The correct action is for the LPN to take vital signs and then ask the charge RN to administer the PRBCs. This ensures patient safety, complies with the Nurse Practice Act, and maintains proper delegation.

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Which instruction would the nurse give when instructing the UAP (unlicensed assistive personnel) to give a complete bed bath to a patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The Licensed Practical Nurse (LPN) will anticipate that the patient with restraints will need which additional care?

Correct Answer is D

Explanation

The physician gives the LPN an order to administer a bag of Packed Red Blood Cells (PRBCs) to a patient with a low hemoglobin. According to the Nurse Practice Act, which action by the LPN is correct?

Correct Answer is D

Explanation

The nurse is applying personal protective equipment (PPE) prior to entering a client’s room. What is the correct sequence for donning (putting on) PPE?

According to the State Nurse Practice Act, which of the following actions are expectations of a student nurse? (Select all that apply)

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The UAP (Unlicensed Assistive Personnel) has just completed taking vital signs. She notifies the nurse of the results. Based on these results with adult patients, which patient would the nurse be most concerned about?

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