A nurse who works in a long-term care facility is delegating aspects of client care to unlicensed assistive personnel (UAP). Which assignment(s) should the nurse delegate? (Select all that apply.)

Identify locations of skin lesions on a newly admitted client.

Empty the ostomy bag for a client with a temporary colostomy.

Provide a complete bed bath for a comatose client.

Perform foot care including toenail trimming and heel care.

Give mouth care to an elderly client who has a tracheostomy.

Answer and Explanation

Correct Answer : B,C

Choice A Reason: Identifying locations of skin lesions on a newly admitted client is a nursing assessment that requires clinical judgment and cannot be delegated to the UAP.

Choice B Reason: Emptying the ostomy bag for a client with a temporary colostomy is a routine task that does not require clinical judgment and can be delegated to the UAP.

Choice C Reason: Providing a complete bed bath for a comatose client is a routine task that does not require clinical judgment and can be delegated to the UAP.

Choice D Reason: Performing foot care including toenail trimming and heel care is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP. The UAP may cause injury or infection to the client's feet, especially if the client has diabetes or peripheral vascular disease.

Choice E Reason: Giving mouth care to an elderly client who has a tracheostomy is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP. The UAP may cause trauma or aspiration to the client's trachea, especially if the client has poor oral hygiene or respiratory secretions.

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Correct Answer is B

Explanation

Choice A Reason: This is not the first priority because it does not address the client's safety and well-being. The charge nurse should inform the pharmacist who dispensed the medication, but this can be done later.

Choice B Reason: This is the best action because it protects the client from harm and prevents further complications. The charge nurse should evaluate the client for symptoms of a drug overdose, such as nausea, vomiting, drowsiness, or respiratory depression, and administer antidotes or supportive measures if needed.

Choice C Reason: This is not the first priority because it does not provide immediate care to the client. The charge nurse should report the medication error to the nursing supervisor, but this can be done later.

Choice D Reason: This is not the first priority because it does not correct the mistake or prevent recurrence. The charge nurse should review the medication transcription with the nurse, but this can be done later.

A. Notify the healthcare provider. B. Monitor for signs of bleeding. C. Complete an adverse occurrence report. D. Obtain blood for coagulation studies.

Correct Answer is A

Explanation

Choice A Reason: This is the correct answer because the nurse should immediately inform the healthcare provider of the medication error and the client's condition. The healthcare provider may order antidotes, such as protamine sulfate for heparin and vitamin K for warfarin, to reverse the anticoagulant effects and prevent bleeding complications.

Choice B Reason: Monitoring for signs of bleeding is important but not the priority action for the nurse because it does not address the cause of the problem or prevent further harm. The nurse should monitor the client's vital signs, hemoglobin, hematocrit, and urine output, as well as check for any signs of bleeding, such as bruising, petechiae,

hematuria, hematemesis, melena, or epistaxis.

Choice C Reason: Completing an adverse occurrence report is important but not the priority action for the nurse because it does not provide immediate intervention or treatment for the client. The nurse should complete an

adverse occurrence report after notifying the healthcare provider and implementing appropriate actions. The report should include the details of the error, such as the time, dose, route, and name of the medications involved, as well as the client's response and outcome.

Choice D Reason: Obtaining blood for coagulation studies is important but not the priority action for the nurse because it does not provide immediate intervention or treatment for the client. The nurse should obtain blood

samples for coagulation studies, such as prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (aPTT), after notifying the healthcare provider and following their orders. The results of these tests can help determine the extent of anticoagulation and guide further therapy.

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A nurse who works in a long-term care facility is delegating aspects of client care to unlicensed assistive personnel (UAP). Which assignment(s) should the nurse delegate? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is A

Explanation

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