The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the PN?

Begin initial sterile wound care for surgical clients.

Validate prescribed intravenous flow rates.

Determine the need for urinary catheterizations.

Receive a postoperative client and conduct the assessment.

Answer and Explanation

The Correct Answer is B

Choice A Reason: Beginning initial sterile wound care for surgical clients is a nursing intervention that requires clinical judgment and cannot be delegated to the PN. The PN may assist with wound care after the initial dressing change, but the RN is responsible for assessing the wound and initiating the plan of care.

Choice B Reason: Validating prescribed intravenous flow rates is a routine task that does not require clinical judgment and can be delegated to the PN. The PN has the knowledge and skill to check the IV orders, calculate the drip rate, and monitor the infusion.

Choice C Reason: Determining the need for urinary catheterizations is a nursing assessment that requires clinical judgment and cannot be delegated to the PN. The PN may perform urinary catheterizations as ordered by the physician, but the RN is responsible for evaluating the indication, risk, and benefit of the procedure.

Choice D Reason: Receiving a postoperative client and conducting the assessment is a nursing intervention that requires clinical judgment and cannot be delegated to the PN. The RN is responsible for receiving reports from the operating room, assessing the client's status, identifying potential complications, and initiating the plan of care.

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Correct Answer is ["B","C"]

Explanation

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.

A. A male adolescent who has been vomiting for the past 12 hours and describes himself as very weak. B. A female client with severe right lower abdominal pain who is febrile and vomiting. C. An elderly client with peripheral vascular disease who is complaining of severe leg pain when ambulating. D. A child who has had a cold for two days and now is coughing up green sputum.

Correct Answer is B

Explanation

Choice A Reason: This is not the first priority because it is not a life-threatening condition. The male adolescent may have gastroenteritis or food poisoning, which can cause dehydration and electrolyte imbalance. The nurse should monitor his vital signs and fluid intake, but he can wait for further assessment.

Choice B Reason: This is the first priority because it is a potential surgical emergency. The female client may have appendicitis, which can cause peritonitis and sepsis if left untreated. The nurse should assess her pain level, vital signs, and abdominal signs, and prepare her for diagnostic tests and possible surgery.

Choice C Reason: This is not the first priority because it is a chronic condition that does not require immediate intervention. The elderly client may have intermittent claudication, which is a symptom of peripheral arterial disease. The nurse should educate him on leg care and exercise, but he can wait for further assessment.

Choice D Reason: This is not the first priority because it is a common condition that can be treated with antibiotics. The child may have a bacterial infection, such as bronchitis or pneumonia, which can cause productive cough and fever. The nurse should auscultate his lungs and check his temperature, but he can wait for further assessment.

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The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the PN?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C"]

Explanation

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Correct Answer is B

Explanation

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