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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Disinfecting equipment is a routine infection control measure that UAPs can perform after receiving proper training on the protocol. This activity does not require clinical judgment and falls within the
UAP’s responsibilities.
B. While UAPs may assist in educating visitors about hand hygiene, the demonstration of correct hand washing techniques is typically a nursing responsibility. Nurses are trained to provide this education effectively and ensure that the information is conveyed appropriately, especially since it may involve assessing visitors’ understanding.
C. This task requires clinical judgment and assessment skills, which are within the nursing scope of practice. Nurses need to evaluate this information in the context of the client’s overall health and care plan, making it inappropriate for delegation to UAP.
D. Screening for symptoms involves assessment and interpretation, which require a nursing level of knowledge and clinical judgment. While UAPs may collect basic data or report observations, actively screening clients for specific symptoms should be performed by a nurse.
Correct Answer is C
Explanation
A. While low ferritin levels can indicate iron deficiency anemia, sickle cell anemia primarily involves the production of abnormal hemoglobin rather than iron deficiency. Fatigue in sickle cell anemia is more closely related to the effects of the disease itself, including chronic hemolysis and decreased red blood cell survival.
B. Sickle cell anemia is not classified as an autoimmune disease; it is a genetic disorder caused by a mutation in the hemoglobin gene. While individuals with sickle cell anemia may have increased susceptibility to infections, the fatigue they experience is not due to an autoimmune process.
C. Sickle cell anemia leads to chronic hemolytic anemia, meaning the abnormal sickle-shaped red blood cells break down more quickly than normal red blood cells. This results in a lower overall red blood cell count (anemia), which can cause fatigue and weakness due to reduced oxygen-carrying capacity in the blood.
D. While gastrointestinal bleeding can lead to fatigue due to blood loss and subsequent anemia, it is not a direct consequence of sickle cell anemia. If the client had experienced a gastrointestinal bleed, it would typically need to be evaluated independently of their sickle cell disease.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.