Which tasks can be delegated to unlicensed assistive personnel? Select all that apply.
Assessing the client for pain.
Obtaining vital signs on a stable client.
Providing discharge teaching.
Performing a dressing change.
Meeting self-care deficit needs for the client.
Performing phlebotomy (blood draws).
Correct Answer : B,E,F
Choice A rationale
Assessment is a core part of the nursing process that requires clinical judgment and specialized knowledge. The registered nurse must evaluate the nature, intensity, and location of pain to develop an appropriate plan of care. Unlicensed personnel lack the training to interpret physiological and psychological data. Delegating assessment can lead to missed complications or delayed treatment. Therefore, the nurse remains responsible for all patient assessments.
Choice B rationale
Obtaining vital signs is a routine, technical task that can be safely delegated when the patient is physiologically stable. The assistant must be trained in the procedure and know the parameters to report. The nurse retains responsibility for interpreting these values in the context of the patient's condition. Normal adult vital signs typically include a heart rate of 60 to 100 beats per minute and a respiratory rate of 12 to 20 breaths.
Choice C rationale
Discharge teaching involves complex education regarding medications, activity restrictions, and follow-up care tailored to the patient's specific needs. This task requires the pedagogical skills and clinical expertise of a registered nurse. Unlicensed staff are not qualified to provide formal education or evaluate the patient's readiness for discharge. Effective teaching ensures patient safety and reduces readmission rates. The nurse must document the patient's understanding and any barriers to learning encountered during the session.
Choice D rationale
Dressing changes for surgical or complex wounds often require sterile technique and the ability to assess wound healing or signs of infection. These tasks are generally outside the scope of unlicensed personnel unless the wound is simple and chronic. The nurse must inspect the site for redness, edema, or purulent drainage. Improper technique by untrained staff can introduce pathogens, leading to sepsis or delayed recovery. Clinical judgment is necessary during the procedure.
Choice E rationale
Assisting with activities of daily living is a fundamental role of unlicensed personnel. This includes helping patients with bathing, dressing, and feeding to meet self-care deficits. These tasks are repetitive and do not require the complex clinical judgment of a licensed professional. By delegating these duties, the nurse can focus on higher-level clinical interventions. However, the nurse must still supervise and ensure the patient's safety and comfort are maintained during these activities.
Choice F rationale
Phlebotomy is a technical skill that many facilities allow trained unlicensed personnel to perform once they have demonstrated competency. This involves the collection of blood samples for laboratory analysis while maintaining aseptic technique. While it requires precision, it does not involve the diagnostic assessment or clinical reasoning reserved for the nurse. The nurse must ensure the samples are labeled correctly and sent to the lab promptly. Success depends on following strict facility protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Directing the toddler to look downward actually positions the cornea in the path of the medication application, increasing the risk of irritation or injury. For proper administration of ophthalmic ointment, the patient should be instructed to look upward. This action exposes the lower conjunctival sac and moves the sensitive cornea away from the tip of the tube, ensuring the medication is deposited safely and effectively without causing corneal trauma.
Choice B rationale
Applying the ointment in a thin line along the lower conjunctival sac is the standard technique for ophthalmic medications. This anatomical space allows the medication to be distributed evenly across the ocular surface as the patient blinks. A thin line is sufficient to achieve therapeutic levels of the antibiotic while minimizing blurred vision. This method ensures the medication contacts the inflamed conjunctiva directly to treat the bacterial infection efficiently while avoiding excessive wastage.
Choice C rationale
Cleaning secretions from the outer to the inner canthus is incorrect because it risks pushing contaminated material and pathogens into the lacrimal duct and the opposite eye. The correct technique is to wipe from the inner canthus toward the outer canthus. This direction follows the natural flow of tears and moves bacteria away from the nasolacrimal system, thereby preventing the spread of infection and maintaining better ocular hygiene during the treatment.
Choice D rationale
Using a sterile glove and applicator is unnecessary for the application of ophthalmic ointment and may be cumbersome when treating a toddler. The nurse should instruct the caregiver to wash their hands thoroughly before and after the procedure. The tip of the ointment tube must remain sterile and should not touch the eye or any other surface. Hand hygiene and careful technique are sufficient to prevent cross-contamination without needing specialized sterile equipment.
Correct Answer is D
Explanation
Choice A rationale
Family history reflects the inherited susceptibility to specific conditions based on the health patterns of biological relatives. While it provides critical data for screening and early detection, an individual cannot change their ancestral lineage or the health events of their parents and siblings. Because these genetic predispositions are fixed at birth, they are classified as non-modifiable risk factors in epidemiological studies and clinical preventative health assessments.
Choice B rationale
Chronological age is a primary non-modifiable risk factor because the physiological aging process involves progressive cellular decline and increased vulnerability to chronic diseases. As time passes, the cumulative exposure to environmental stressors and the natural reduction in homeostatic efficiency cannot be reversed. In disease pathology, age-related changes in organ function and immune response are inevitable, making it a constant variable that healthcare providers must account for without the possibility of alteration.
Choice C rationale
Genetics involves the specific DNA sequences and chromosomal structures inherited from biological parents that determine various health traits and disease predispositions. Genomic science confirms that while lifestyle can influence gene expression through epigenetics, the underlying genetic code itself remains unchanged throughout a person's life. Therefore, genetic mutations or hereditary markers for conditions like cystic fibrosis or certain cancers are fundamental non-modifiable factors that dictate baseline health risks.
Choice D rationale
Sunbathing is a behavioral choice involving exposure to ultraviolet radiation, which is a known carcinogen for skin cells. Unlike age or genetics, an individual can choose to limit sun exposure, use protective clothing, or apply sunscreen to reduce the risk of developing melanoma or basal cell carcinoma. Because this behavior is under the direct control of the individual and can be altered through education and lifestyle changes, it is classified as a modifiable risk factor.
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