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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).

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

A respiratory rate of 28/min is considered tachypneic, as the normal range for an adult is typically 12 to 20 breaths per minute. An elevated respiratory rate suggests that the body is still struggling to compensate for low oxygen levels or high carbon dioxide. Therefore, this finding would indicate that the oxygen therapy has not yet fully stabilized the client's respiratory status. Effective intervention should result in the respiratory rate returning toward the normal physiological range.

Choice B rationale

Pink mucous membranes are a primary indicator of adequate tissue perfusion and oxygenation of hemoglobin. When hypoxia is present, membranes may appear pale or cyanotic due to the lack of oxygenated blood. The transition to pink signifies that the supplemental oxygen is effectively increasing the arterial oxygen tension and saturating the hemoglobin molecules. This clinical observation is a reliable sign that the oxygen therapy is successfully delivering necessary oxygen to the systemic peripheral tissues.

Choice C rationale

Restlessness is a common early neurological sign of hypoxia and cellular oxygen deprivation within the cerebral cortex. As oxygen levels drop, the brain triggers a stress response that manifests as agitation, anxiety, or confusion. If the client remains restless, it suggests that the supplemental oxygen has not yet resolved the underlying hypoxia at the cellular level. A successful intervention would typically lead to a calmer, more alert state as brain tissue receives sufficient oxygenation.

Choice D rationale

A heart rate of 110/min is classified as tachycardia, exceeding the normal adult resting range of 60 to 100 beats per minute. Tachycardia is a compensatory mechanism where the heart pumps faster to circulate limited oxygen to vital organs. If the heart rate remains elevated, it indicates that the cardiovascular system is still under stress from oxygen deficiency. Effective oxygen therapy should reduce the workload on the heart, leading to a decrease in the pulse rate.

A. Phosphate. B. Carbon dioxide. C. Bicarbonate. D. Potassium.

Correct Answer is D

Explanation

Choice A rationale

Phosphate levels are generally not the primary concern when administering loop diuretics like furosemide. While diuretics can affect various electrolytes, the most significant life-threatening imbalances caused by furosemide involve potassium and sodium. Normal serum phosphate ranges from 3.0 to 4.5 mg/dL. While it is important to monitor overall metabolic status in heart failure patients, phosphate does not have the same immediate impact on cardiac rhythm and muscle function as potassium does during diuretic therapy.

Choice B rationale

Carbon dioxide levels in a metabolic panel reflect the bicarbonate concentration and the acid-base balance of the blood. While loop diuretics can cause metabolic alkalosis, which would increase these levels, it is not the most critical parameter to check before a single dose. Normal venous carbon dioxide levels range from 23 to 30 mEq/L. The priority is to assess for electrolyte deficiencies that could cause immediate cardiac complications, making potassium a more vital laboratory value to review.

Choice C rationale

Bicarbonate levels are an indicator of the body's acid-base status. Furosemide can lead to contraction alkalosis, causing an increase in bicarbonate levels over time. Normal bicarbonate levels range from 22 to 28 mEq/L. While monitoring for alkalosis is part of long-term care for clients on diuretics, it is not the priority assessment before drug administration. The nurse must prioritize electrolytes that directly influence heart rate and rhythm in the context of heart failure and loop diuretic use.

Choice D rationale

Furosemide is a loop diuretic that inhibits the reabsorption of sodium, chloride, and water in the ascending limb of the loop of Henle, leading to increased excretion of potassium. Normal serum potassium levels are 3.5 to 5.0 mEq/L. Administering furosemide to a client with hypokalemia can lead to life-threatening cardiac arrhythmias. Because heart failure patients often take other medications like digoxin, low potassium significantly increases the risk of toxicity and must be verified before administration.

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Which tasks can be delegated to unlicensed assistive personnel? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicate the intervention was effective?

Correct Answer is B

Explanation

A nurse is caring for a client who has heart failure and a new prescription for furosemide. Which of the following laboratory values should the nurse review before administering furosemide?

Correct Answer is D

Explanation

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