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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Related Questions
Correct Answer is A
Explanation
A. This side effect, known as myelosuppression, is a significant concern and can manifest as anemia.
B. Hydroxyurea is actually prescribed to reduce the frequency of vasoocclusive crises by increasing fetal hemoglobin levels, which helps to prevent sickling of red blood cells. While a patient might experience pain crises while on hydroxyurea, the medication is intended to help manage this issue rather than be a reason for discontinuation.
C. While gastrointestinal upset is also a possible side effect, the risk of severe blood-related complications typically takes precedence when considering the discontinuation of hydroxyurea
D. While allergic reactions like itching or hives can occur with many medications, they are less common with hydroxyurea specifically.
Correct Answer is A
Explanation
A. This action exemplifies nursing advocacy. Ensuring that a client has given informed consent means that the nurse is making sure the patient understands their treatment options, the risks involved, and the potential benefits.
B. While sharing experiences can be helpful, influencing a client’s decision based on the nurse's own experiences can compromise the client’s autonomy. Advocacy means supporting the patient in making their own informed choices rather than directing them toward a specific decision.
C. Discussing a client’s medical treatment with someone who is not part of the healthcare team or not authorized to receive that information violates patient confidentiality and privacy rights. Advocacy includes respecting the client’s right to privacy and not disclosing information without consent.
D. While nurses can provide education and information about treatment options, recommending specific surgical or treatment options is generally outside the scope of nursing practice. Advocacy involves helping clients understand their options and supporting them in their decisions, not directing them toward specific interventions.
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