The nurse is providing education to a student nurse regarding delegation. What tasks would be unable to be delegated to unlicensed assistive personnel (UAP)? (Select all that apply)

Providing a bed bath

Assisting in toileting

Evaluate effectiveness of a treatment

Assessment of a stoma

Discharge teaching

Answer and Explanation

Correct Answer : C,D,E

Choice A Reason:

Providing a bed bath is a task that can be delegated to unlicensed assistive personnel (UAP). This task is routine and does not require clinical judgment or advanced nursing skills. UAPs are trained to perform basic care activities such as bathing, which helps maintain the client’s hygiene and comfort.

Choice B Reason:

Assisting in toileting is another task that can be delegated to UAPs. This task involves helping clients with their toileting needs, which is within the scope of practice for UAPs. It does not require the clinical judgment or assessment skills that are reserved for licensed nurses.

Choice C Reason:

Evaluating the effectiveness of a treatment is a task that cannot be delegated to UAPs. This task requires clinical judgment and the ability to assess the client’s response to treatment, which are responsibilities of licensed nurses. Only licensed nurses have the training and expertise to evaluate treatment outcomes and make necessary adjustments.

Choice D Reason:

Assessment of a stoma is a task that cannot be delegated to UAPs. Assessing a stoma involves evaluating its appearance, function, and any signs of complications, which requires clinical judgment and expertise. This task is within the scope of practice for licensed nurses, who are trained to perform comprehensive assessments.

Choice E Reason:

Discharge teaching is a task that cannot be delegated to UAPs. Discharge teaching involves providing clients with important information about their care after leaving the healthcare facility, including medication instructions, follow-up appointments, and lifestyle modifications. This task requires clinical knowledge and the ability to educate clients effectively, which are responsibilities of licensed nurses.

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Correct Answer is C

Explanation

Choice A Reason:

Open the client’s visual acuity using a Snellen chart is incorrect. This action assesses cranial nerve II (optic nerve), which is responsible for vision. The Snellen chart is used to measure visual acuity, not the function of cranial nerve VI

Choice B Reason:

Whisper none of the client’s ears while blocking the other is incorrect. This action assesses cranial nerve VIII (vestibulocochlear nerve), which is responsible for hearing and balance. Whispering tests the auditory function of this nerve.

Choice C Reason:

Ask the client to inspect up is correct. Cranial nerve VI (abducens nerve) controls the lateral rectus muscle, which is responsible for moving the eye outward. Asking the client to look up and outward helps assess the function of this nerve.

Choice D Reason:

Ask the client to smile is incorrect. This action assesses cranial nerve VII (facial nerve), which controls the muscles of facial expression. Smiling tests the motor function of this nerve.

A. The pads will keep the staff from workplace injuries such as a pulled muscle. B. The pads will absorb any urinary incontinence and contain stool. C. The pads will help prevent friction and shearing when repositioning the client. D. The pads will prevent the client from being diaphoretic.

Correct Answer is C

Explanation

Choice A reason: While lift pads can help reduce the risk of workplace injuries for staff, such as pulled muscles, this is not their primary purpose. The main goal of using lift pads is to protect the client from injury during repositioning. Lift pads distribute the client’s weight more evenly, making it easier for staff to move them without straining themselves.

Choice B reason: Lift pads are not designed to absorb urinary incontinence or contain stool. There are specific products like incontinence pads and briefs for managing urinary and fecal incontinence. Lift pads are primarily used to assist with the safe repositioning of immobile clients.

Choice C reason: The primary purpose of lift pads is to help prevent friction and shearing when repositioning the client. Friction and shearing can cause skin damage and pressure ulcers, especially in immobile clients. Lift pads reduce the risk of these injuries by allowing smoother and safer movements.

Choice D reason: Lift pads do not prevent clients from being diaphoretic (sweating excessively). Diaphoresis can be managed through other means, such as adjusting room temperature, using fans, or providing appropriate clothing and bedding. Lift pads are not intended for this purpose.

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The nurse is providing education to a student nurse regarding delegation. What tasks would be unable to be delegated to unlicensed assistive personnel (UAP)? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to assess a client. Which action should the nurse take to check cranial nerve VI?

Correct Answer is C

Explanation

A nurse is providing an in-service about repositioning clients and the use of lift pads for immobile clients. What is the rationale for placing lift pads under an immobile client?

Correct Answer is C

Explanation

A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client’s consent form. The nurse’s signature on the consent form indicates which of the following?

A nurse is caring for a client who will be placed on strict bed rest after surgery. The nurse should educate the client on the use of an incentive spirometer. The use of an incentive spirometer would prevent which postoperative complication?

A nurse accidentally sticks her hand with a needle after administering an intramuscular (IM) injection to a client. Which action should the nurse take first?

A nurse is assessing a client with congestive heart failure (CHF). Which assessment tool will provide a reliable measure of fluid retention for this client?

A nurse is teaching a client who is obese and has obstructive sleep apnea on how to decrease the number of nightly apneic episodes. Which client statement indicates an understanding of the teaching?

A nurse is assessing for jaundice on a dark-skinned client. Which site should the nurse examine to identify jaundice on this client?

A nurse is assessing a client who is 2 days postoperative and is auscultating their bilateral breath sounds. The nurse notes absent breath sounds in the bases. The nurse should suspect which postoperative complication is occurring in this client?