Which task could a nurse delegate to unlicensed assistive personnel (UAP) assigned to a cardiac surgery unit?

Teaching a client how to use a pillow to support an incision when coughing.

Checking the pedal pulses of the bed-bound clients.

Ambulating the first-day postoperative clients.

Emptying the urine drainage bags at least once per shift.

Answer and Explanation

The Correct Answer is D

Emptying the urine drainage bags at least once per shift is a task that can be delegated to unlicensed assistive personnel (UAP) assigned to a cardiac surgery unit.

This task does not require assessment, teaching, or evaluation skills that are beyond the scope of practice of UAP.

Choice A is wrong because teaching a client how to use a pillow to support an incision when coughing requires education and evaluation skills that are only within the scope of practice of licensed nurses.

Choice B is wrong because checking the pedal pulses of bed-bound clients requires assessment skills that are only within the scope of practice of licensed nurses.

Pedal pulses are important indicators of peripheral circulation and vascular status.

Choice C is wrong because ambulating the first-day postoperative clients requires assessment and evaluation skills that are only within the scope of practice of licensed nurses.

First-day postoperative clients may have complications such as bleeding, infection, or hypotension that need to be monitored by a nurse.

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Correct Answer is D

Explanation

30 to 40 mL/hour. This is the normal range of urine output for a typical adult client. The urine output should be at least 0.5 mL/kg/hour for adults.

Assuming an average weight of 70 kg, this would be 35 mL/hour.

Choice A is wrong because 5 to 10 mL/hour is too low and indicates oliguria, which is a sign of inadequate kidney function or dehydration.

Choice B is wrong because 12 to 15 mL/hour is also below the normal range and may indicate oliguria.

Choice C is wrong because 16 to 25 mL/hour is slightly below the normal range and may indicate reduced kidney perfusion or fluid intake.

A. Visual inspection of skin for placement. B. Positioning for proper body alignment. C. Assess the need for restraints placement. D. Review facility policy before usage.

Correct Answer is C

Explanation

This is because restraints should only be used as a last resort when other alternatives have failed to ensure the patient’s safety and when there is a valid order from the primary healthcare provider.

Assessing the need for restraints placement involves evaluating the patient’s condition, behavior, risk factors, and potential benefits and harms of using restraints.

Choice A is wrong because visual inspection of skin for placement is done after applying restraints, not before.

This is to check for any signs of injury, irritation, or circulation impairment caused by the restraints.

Choice B is wrong because positioning for proper body alignment is done during and after applying restraints, not before.

This is to prevent complications such as pressure ulcers, contractures, or nerve damage due to improper positioning.

Choice D is wrong because reviewing facility policy before usage is not a nursing intervention, but a legal and ethical requirement.

Nurses should be familiar with the facility policy and guidelines regarding the use of restraints and follow them accordingly.

However, this does not replace the need for individualized assessment and evaluation of each patient’s situation.

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Which task could a nurse delegate to unlicensed assistive personnel (UAP) assigned to a cardiac surgery unit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which amount of urine production should the nurse evaluate as adequate output for a typical adult client?

Correct Answer is D

Explanation

Which nursing intervention should be performed before applying client restraints?

Correct Answer is C

Explanation

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