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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because a client with obstructive sleep apnea (OSA) may have periods of apnea lasting more than 10 seconds during sleep, which can lead to hypoxia and hypercapnia. These conditions can cause the client to be difficult to arouse and may indicate respiratory failure.
The nurse should take immediate action to stimulate the client, provide oxygen, and call for help.
Choice B is wrong because blood pressure 142/92 mmHg is not an emergency for a client with OSA. It is within the stage 1 hypertension range, which may be caused by OSA or other factors. The nurse should monitor the client’s blood pressure and encourage lifestyle modifications, such as weight loss, exercise, and dietary changes.
Choice C is wrong because apneic periods lasting more than 10 seconds are expected in a client with OSA. This is the criterion for diagnosing OSA during a sleep study. The nurse should educate the client about the use of continuous positive airway pressure (CPAP) or other treatments to prevent apnea and improve oxygenation during sleep.
Choice D is wrong because oxygen desaturation to 90% when asleep is not an emergency for a client with OSA. It is a common finding in OSA due to the intermittent obstruction of the upper airway. The nurse should ensure that the client has supplemental oxygen available and teach the client about the benefits of CPAP or other devices to maintain airway patency and oxygen saturation during sleep.
Correct Answer is D
Explanation
A heart murmur is a priority assessment for a toddler who is diagnosed with fetal alcohol syndrome because it may indicate a congenital heart defect, which can affect the child’s growth, development and oxygenation. According to the health search results, fetal alcohol syndrome can cause heart and kidney problems, among other complications.
Choice A is wrong because small head size is a common feature of fetal alcohol syndrome, but it is not a priority assessment. It indicates that the child has microcephaly, which is associated with intellectual and learning disabilities.
Choice B is wrong because poor coordination is another common feature of fetal alcohol syndrome, but it is not a priority assessment. It indicates that the child has problems with motor skills and balance.
Choice C is wrong because speech and language delays are also common features of fetal alcohol syndrome, but they are not a priority assessment. They indicate that the child has problems with communication and social skills.
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