Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?
Call the pharmacy to obtain a client's next antibiotic dose.
Observe a client's gait to determine the need for assistance.
Bring a sterile chest drainage unit from central supply to the unit.
Evaluate a client's urinary catheter for proper drainage.
The Correct Answer is C
A. This task is beyond the scope of practice for a UAP. Calling the pharmacy to obtain medications requires clinical judgment and understanding of medication administration, which is the responsibility of licensed nursing personnel. B. This task requires assessment skills, which are beyond the scope of practice for a UAP. Determining a client's need for assistance with mobility requires clinical judgment. C. This task is appropriate to delegate to a UAP. It involves transporting an item from one location to another, which does not require clinical judgment or assessment. D. This task requires assessment skills and clinical judgment, which are beyond the scope of practice for a UAP. Evaluating a client's urinary catheter involves assessing for patency and signs of complications, which should be done by a licensed nurse.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Jaw pain in a client taking alendronate, a bisphosphonate, for postmenopausal osteoporosis may be a sign of a rare but serious side effect called osteonecrosis of the jaw (ONJ). Therefore, the nurse should respond by: Report the client's jaw pain to the healthcare provider.
Jaw pain can be an indication of ONJ, a condition characterized by the death of jawbone tissue. It is important to notify the healthcare provider so that further evaluation and appropriate management can be initiated. The healthcare provider will determine the best course of action, which may include referral to a specialist for further assessment and treatment.
Determining how the client is administering the medication is not the immediate concern in this situation. While it is important to ensure that the client is following proper administration instructions for alendronate, addressing the jaw pain takes precedence.
Advising the client to gargle with warm salt water twice daily may not be sufficient or appropriate for managing jaw pain related to alendronate use. The client needs a comprehensive assessment by the healthcare provider to determine the cause of the jaw pain and provide appropriate interventions.
Confirming that jaw pain is a common symptom of osteoporosis is not accurate. While osteoporosis can lead to bone pain, jaw pain specifically associated with bisphosphonate use is more likely to be related to ONJ and requires further evaluation and management
Correct Answer is D
Explanation
A pounding headache in a client with COPD may be a symptom of increased carbon dioxide (CO2) levels in the blood, known as hypercapnia. Hypercapnia can lead to vasodilation, resulting in headaches. In this situation, it is crucial to assess the client's blood pressure to determine if it is elevated, as this could be contributing to the headache.
Obtaining a manual blood pressure measurement allows for a more accurate assessment of the client's blood pressure compared to automated measurements. It is important to assess both systolic and diastolic blood pressures, as elevated blood pressure can worsen headaches and have other negative effects on the client's health.
Elevating the head of the bed no higher than 30 degrees is a general measure used to improve respiratory function in clients with COPD. However, in this specific situation, it may not directly address the pounding headache. Elevating the head of the bed can help reduce dyspnea and improve oxygenation, but it may not alleviate the headache caused by hypercapnia.
Affirming blood glucose levels are below 160 mg/dL (8.88 mmol/L) is not the primary concern in this case. While high blood glucose levels can have various effects on the body, including headaches, the priority is to assess the client's blood pressure due to the specific context of a COPD exacerbation.
Checking for a stat intravenous diuretic prescription is not necessary in response to the client's headache. Diuretics are typically used to remove excess fluid from the body and may not directly address the underlying cause of the headache in this situation.
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