The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. Which client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.).

Obtain a post-voided residual (PVR) volume.

Teach the client with fluid restrictions how to measure urine output.

Empty bedside drainage unit for a client with an indwelling urinary catheter.

Irrigate an indwelling urinary catheter for a client with bladder suspension.

Transport a urine culture sample to the laboratory.

Answer and Explanation

Correct Answer : A,C,E

Choice A rationale:

Obtaining a post-voided residual (PVR) volume is a non-invasive procedure that can be safely delegated to the unlicensed assistive personnel (UAP) to measure the amount of urine left in the bladder after urination.

Choice B rationale:

Teaching the client with fluid restrictions how to measure urine output requires specialized knowledge and is best performed by the practical nurse (PN).

Choice C rationale:

Emptying the bedside drainage unit for a client with an indwelling urinary catheter is a task that can be delegated to the UAP as it involves routine drainage and does not require advanced nursing skills.

Choice D rationale:

Irrigating an indwelling urinary catheter for a client with bladder suspension is a sterile procedure that requires nursing expertise, so it should not be assigned to the unlicensed assistive personnel.

Choice E rationale:

Transporting a urine culture sample to the laboratory is a non-complex task that can be safely delegated to the UAP to ensure timely and efficient delivery.

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Correct Answer is B

Explanation

Choice A rationale:

While measuring urinary output is an important nursing intervention, it may not be the most critical action for a client with left-sided heart failure. Left-sided heart failure primarily affectspulmonary circulation, and assessing lung sounds is a priority in this situation.

Choice C rationale:

Checking mental acuity is a valid nursing intervention, but it may not be the most crucial action for a client with left-sided heart failure. The priority in this case is to monitor respiratory status and identify any signs of respiratory distress.

Choice D rationale:

Inspecting for sacral edema is also a relevant nursing intervention, as it can indicate fluid retention in heart failure patients. However, auscultating the lung fields takes precedence in this scenario to assess for signs of pulmonary congestion, which is a common complication of left-sided heart failure.

A. Include "Noncompliance”. as a priority problem in the client's plan of care. B. Advise the UAP to re-attempt the daily weight after the client eats breakfast. C. Consult with the client about the reasons for his refusal to be weighed D. Calculate the client's weight based on the 24-hour fluid intake and output.

Correct Answer is C

Explanation

The correct answer is choice C. Consult with the client about the reasons for his refusal to be weighed.

Choice A rationale:

Including "Noncompliance”. as a priority problem in the client's plan of care assumes the client's refusal to be weighed is intentional and willfully disobedient. This may not be the case, and labeling the client as noncompliant could create a negative atmosphere, hindering effective communication and care.

Choice B rationale:

Advising the UAP to re-attempt the daily weight after the client eats breakfast does not address the underlying reason for the client's refusal. Additionally, there is no evidence suggesting that weighing the client after breakfast will improve the situation.

Choice C rationale:

Consulting with the client about the reasons for his refusal to be weighed is the most appropriate action. Open communication with the client can help identify any concerns or fears related to the weighing process. By understanding the client's perspective, the healthcare team can work together to find a solution that ensures the client's cooperation with the weight monitoring.

Choice D rationale:

Calculating the client's weight based on the 24-hour fluid intake and output is not a reliable method for obtaining an accurate weight measurement. Fluid volume overload can lead to fluid retention and may not accurately reflect the client's true weight.

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The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. Which client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

Correct Answer is B

Explanation

The unlicensed assistive personnel (UAP) reports to the practical nurse (PN) that a male clientwith fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the PN implement?

Correct Answer is C

Explanation

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

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The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?