Which type of task may appropriately be delegated to an unlicensed assistive personnel?
Evaluating a client's response to medication.
Taking and reporting routine vital signs.
Developing a teaching plan for discharge.
Assessing a client's level of pain after surgery.
The Correct Answer is B
Choice A rationale
Evaluating a client's response to medication is a complex nursing function that requires clinical judgment, knowledge of pharmacology, and assessment skills. This task involves comparing the expected therapeutic effects with the actual outcomes and identifying any adverse reactions. Because evaluation is a core component of the nursing process (ADPIE), it cannot be delegated to unlicensed assistive personnel. The registered nurse is responsible for interpreting data and making decisions about the effectiveness of the treatment plan for the patient.
Choice B rationale
Taking and reporting routine vital signs is a standard task that can be safely delegated to unlicensed assistive personnel in stable situations. This task is procedural and does not require advanced clinical judgment to perform the measurement itself. However, the nurse remains responsible for interpreting the results and determining if they are within normal limits for the specific patient. Normal ranges include blood pressure < 120/80 mmHg, heart rate 60 to 100 beats, and respiratory rate 12 to 20.
Choice C rationale
Developing a teaching plan for discharge involves assessing the learner's needs, identifying goals, and selecting appropriate educational strategies. This is a highly individualized process that requires professional knowledge of disease processes and teaching-learning principles. Unlicensed personnel do not have the training to create or modify care plans or educational materials. The registered nurse must lead the discharge planning process to ensure that the patient receives accurate and comprehensive information necessary for safe care at home.
Choice D rationale
Assessing a client's level of pain after surgery is a professional nursing responsibility that involves more than just asking for a number on a scale. It requires an understanding of the surgical procedure, potential complications, and the timing of analgesic administration. The nurse must interpret the pain within the clinical context of the patient's recovery. Since assessment is the first step of the nursing process and requires clinical judgment, it is not appropriate to delegate to unlicensed staff.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Angina is a clinical syndrome characterized by chest pain or pressure resulting from myocardial ischemia. It occurs when the oxygen demand of the heart muscle exceeds the supply provided by the coronary arteries, often due to atherosclerosis. While it involves a localized supply-demand mismatch in the heart itself, it does not define the systemic state where the heart fails as a pump to maintain adequate circulation and oxygenation to all the peripheral tissues of the body.
Choice B rationale
Heart failure is the correct term for the physiological state in which the heart is unable to pump blood at a rate sufficient to meet the metabolic requirements of the tissues. This results in inadequate systemic perfusion and tissue oxygenation. It can be caused by structural or functional abnormalities that impair the ability of the ventricles to fill with or eject blood. This leads to symptoms such as fatigue, dyspnea, and fluid retention throughout the body systems.
Choice C rationale
A dysrhythmia refers to any abnormality in the rate, regularity, or sequence of cardiac depolarization and repolarization. While some dysrhythmias, such as ventricular fibrillation or severe bradycardia, can lead to decreased cardiac output and poor perfusion, the term itself only describes the electrical activity of the heart. It is not synonymous with the overall pumping failure of the heart, as many dysrhythmias do not immediately result in systemic tissue hypoxia or global perfusion deficits.
Choice D rationale
Myocardial infarction occurs when blood flow to a specific part of the heart muscle is blocked, leading to the death of cardiac myocytes. While a large myocardial infarction can certainly cause heart failure by damaging the pumping mechanism, the infarction itself is an acute ischemic event. Heart failure is the broader clinical condition and resulting syndrome of inadequate systemic perfusion that may or may not be triggered by a specific event like an acute myocardial infarction.
Correct Answer is C
Explanation
Choice A rationale
Bathing is generally discouraged for individuals prone to urinary tract infections because sitting in soapy water can allow bacteria to enter the urethra. Showering is preferred as it washes bacteria away from the urethral opening. The proximity of the anus to the urethra in females increases the risk of Escherichia coli migration. Therefore, recommending baths over showers is scientifically incorrect for infection prevention and represents a misunderstanding of hygiene-related risks.
Choice B rationale
A post-void residual of 50 milliliters or less is considered a normal finding, indicating that the bladder is emptying effectively. High residual volumes, typically exceeding 100 milliliters, create a stagnant pool of urine that serves as a medium for bacterial growth. Efficient bladder emptying is a primary defense mechanism against infection. Since 50 milliliters is within the healthy range, it is not associated with the development of a urinary tract infection.
Choice C rationale
Urinary tract infections are classified based on their location within the system. Lower infections, such as cystitis, involve the bladder and urethra, while upper infections, like pyelonephritis, involve the ureters and the kidneys. Bacteria usually ascend from the lower tract to the upper tract. Understanding this distinction is critical because upper tract infections are more severe and can lead to systemic sepsis or permanent renal scarring if not treated promptly.
Choice D rationale
Individuals with diabetes mellitus are actually at a significantly higher risk for urinary tract infections. High glucose levels in the urine, known as glycosuria, provide an ideal nutrient source for pathogens like bacteria and yeast. Additionally, diabetic neuropathy can lead to neurogenic bladder and incomplete emptying. Suggesting that infections are uncommon in this population contradicts established pathophysiology regarding metabolic disorders and their impact on immune function and urinary health.
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