The care of a client is assigned to a newly-graduated RN. What actions can the newly-graduated RN delegate to the unlicensed assistive personnel (UAP)? [SELECT ALL THAT APPLY]
Providing oral care every 3 to 4 hours.
Help the client change position every 2 hours.
Administering 0.45% saline by IV line.
Record urine output when client voids.
Monitoring for indications of dehydration.
Assessing daily weights for trends.
Correct Answer : A,B,D
A. This task is appropriate for UAP to perform, as it involves basic hygiene and does not require nursing judgment or clinical assessment. UAP can assist with routine oral care under the direction of the RN.
B. Assisting with position changes is a basic care activity that UAP can perform. This task helps prevent pressure ulcers and maintains client comfort, and it does not require the clinical judgment of a nurse.
C. Administering IV medications or fluids is a nursing task that requires specific training and knowledge of nursing assessments, potential complications, and monitoring. This task should only be performed by a licensed nurse, not by UAP.
D. UAP can document basic measurements such as urine output, as this is a straightforward task that does not require clinical judgment. However, the RN should ensure that the UAP understands how to accurately measure and record this information.
E. While UAP can observe and report general changes, monitoring for clinical indications of dehydration requires nursing assessment skills and judgment. This task should be performed by an RN.
F. While UAP can weigh clients, the assessment of weight trends requires clinical judgment and interpretation of data, which falls under the responsibilities of a licensed nurse. The RN should evaluate and interpret the data regarding the client's health status.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This statement is the most appropriate for an incident occurrence report. It provides a factual, objective description of what was observed without inferring causes or making assumptions about the patient’s actions. Clear documentation is critical in incident reports for accuracy and potential follow-up.
B. This statement includes assumptions about the patient's motivations and actions. It is speculative and not based on direct observation. Incident reports should avoid subjective interpretations and focus on what can be objectively verified.
C. Although this statement describes a potential scenario, it assumes that the patient was walking to the bathroom and that this was the cause of the fall. Since the nurse did not witness the event, this could be misleading and should be avoided in an incident report.
D. While documenting patient statements can be important, this particular comment is subjective and does not provide an objective account of the incident. It could also lead to potential blame without verifying the accuracy of the statement, which could complicate the report.
Correct Answer is D
Explanation
A. While it is important to address concerns about impairment, confronting the nurse directly can be counterproductive and may escalate the situation. It is essential to approach the situation with caution and follow established protocols for dealing with suspected substance impairment.
B. While gathering observations from colleagues may seem reasonable, it can create a culture of gossip and may violate confidentiality. This approach can also lead to misinformation and should not be the first step in addressing a serious concern about a colleague's safety and well-being.
C. Documenting observations is important, but it should not be the sole action taken at this point. Communicating with the personnel department is part of the process if the situation escalates, but immediate action is necessary to ensure patient safety.
D. This option is the most appropriate initial action. By closely monitoring the nurse’s behavior, the manager can gather more information before taking further steps. This approach allows for the collection of objective data and ensures patient safety while avoiding premature accusations.
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