Which action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel (UAP)?
Check ability to plantar and dorsiflex the foot.
Log roll the patient from side to side every 2 hours.
Ask about pain management with the patient-controlled analgesia (PCA).
Determine the patient's readiness to ambulate.
The Correct Answer is B
Choice A rationale
Checking plantar and dorsiflexion assesses neurological status requiring nursing expertise and cannot be delegated to UAP.
Choice B rationale
Log rolling every 2 hours maintains spinal alignment post-laminectomy, a straightforward, standardized task suitable for experienced UAP.
Choice C rationale
PCA assessment involves evaluating pain control methods, which require critical nursing judgments and is not appropriate to delegate.
Choice D rationale
Determining readiness to ambulate involves comprehensive assessment skills, evaluating multiple factors like pain, strength, and hemodynamic stability, beyond UAP’s scope of practice. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F"]
Explanation
Choice A rationale
Assessing the range of motion of a severely injured leg is not appropriate during initial evaluation. Movement can worsen the injury or disrupt stabilizing measures such as splints or dressings.
Choice B rationale
Asking the patient to stand or bear weight risks further injury and is contraindicated in cases of visible deformity or massive bleeding.
Choice C rationale
Evaluating skin color helps identify potential ischemia, vascular compromise, or inadequate perfusion. Pallor or cyanosis can indicate significant circulation issues needing urgent care.
Choice D rationale
Paresthesia (tingling or numbness) reflects nerve function and can reveal nerve damage or compromised blood flow, necessitating thorough evaluation.
Choice E rationale
Pain assessment is crucial for identifying the severity of injury and potential complications such as compartment syndrome. Pain disproportionate to the injury suggests complications.
Choice F rationale
Palpating pulses assesses blood flow, ensuring the presence of distal perfusion. Absent or weak pulses require urgent vascular intervention to prevent tissue necrosis.
Correct Answer is B
Explanation
Choice A rationale
Administering 1 mg of glucagon intramuscularly stimulates glycogenolysis in the liver, increasing blood glucose levels. However, it is slower in onset compared to IV dextrose, which is critical in a non-arousable patient with a dangerously low blood glucose level of 50 mg/dL. Time efficiency is vital in this emergency.
Choice B rationale
Administering 25 g of dextrose IV pushes glucose directly into the bloodstream, providing an immediate increase in blood glucose. This is the most appropriate action for a non-arousable, hypoglycemic patient. Normal blood glucose ranges between 70-100 mg/dL fasting, making this an emergency requiring prompt correction.
Choice C rationale
Encouraging the patient to eat may be effective in mild hypoglycemia, but not for a critically low level like 50 mg/dL in a non-arousable patient. This delay can result in prolonged neuroglycopenic effects, worsening the patient’s condition.
Choice D rationale
Administering 7 units of Humalog insulin would worsen the hypoglycemia by facilitating glucose uptake into cells, which is contraindicated in this situation. Instead, glucose administration is required to correct the hypoglycemia immediately.
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