Which of the following tasks could the RN delegate to the unlicensed assistive personnel (UAP)?

Irrigate the NG tube with water that is connected to suction for a post-operative client

Perform digital removal of stool on a client who is constipated

Measure the amount of stool in the client’s colostomy bag

Change the saturated central line dressing

Answer and Explanation

The Correct Answer is C

Choice A reason: Irrigating an NG tube involves assessing patency and suction, which requires clinical judgment beyond UAP scope. This task involves potential complications (e.g., aspiration), making it inappropriate for delegation to unlicensed personnel.

Choice B reason: Performing digital removal of stool is a skilled procedure with risks (e.g., vagal stimulation, bleeding), requiring RN expertise. It is outside the UAP scope, as it involves invasive intervention and assessment, making it inappropriate for delegation.

Choice C reason: Measuring stool in a colostomy bag is a routine, non-invasive task within UAP scope, involving observation and reporting output. It requires no clinical judgment or sterile technique, making it the most appropriate task for delegation to unlicensed personnel.

Choice D reason: Changing a central line dressing requires sterile technique and assessment for infection, which are RN responsibilities. UAPs lack training for sterile procedures and complex site evaluation, making this task inappropriate for delegation.

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Correct Answer is C

Explanation

Choice A reason: Coughing and deep breathing improve lung expansion but are less urgent than addressing hypoxemia (88% saturation). Oxygen administration corrects low oxygen levels immediately, making this a secondary action.

Choice B reason: Raising the head of the bed aids breathing by reducing diaphragm pressure, but it does not directly correct hypoxemia. Administering oxygen is the priority to restore saturation, making this less immediate.

Choice C reason: Administering oxygen at 2 L/min is the first action, as 88% saturation indicates hypoxemia, risking organ damage. Oxygen delivery corrects low levels, stabilizing the patient, making this the priority intervention.

Choice D reason: Administering analgesics addresses pain but does not correct hypoxemia. Pain management is secondary to ensuring adequate oxygenation, as low saturation is life-threatening, making this incorrect as the first action.

A. A client who has a prescription for discharge B. A client who told an assistive personnel he is short of breath C. A client who received oral pain medication 30 minutes ago D. A client who is scheduled for physical therapy in 1 hour

Correct Answer is B

Explanation

Choice A reason: A client with a discharge prescription requires attention, but shortness of breath indicates potential respiratory distress, a life-threatening issue. Discharge planning is less urgent, making this a lower priority.

Choice B reason: Shortness of breath suggests possible hypoxia or respiratory compromise, requiring immediate assessment to prevent deterioration. This life-threatening symptom takes precedence over non-urgent issues, making it the priority client to see first.

Choice C reason: A client who received pain medication 30 minutes ago needs monitoring, but shortness of breath is more acute. Pain management is secondary to respiratory distress, making this a lower priority.

Choice D reason: A client scheduled for physical therapy in 1 hour has no immediate needs. Shortness of breath indicates a potential emergency, requiring urgent assessment, making therapy scheduling the least urgent.

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Which of the following tasks could the RN delegate to the unlicensed assistive personnel (UAP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has returned to the unit following a surgical procedure. The client’s oxygen saturation is 88%. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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