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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The client's serum potassium level is elevated at 6.0 mEq/L (6.0 mmol/L), which is above the normal reference range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).
Hyperkalemia can have significant cardiac implications, including the potential for life-threatening dysrhythmias. Therefore, close monitoring of the serum potassium level is crucial to assess the effectiveness of interventions and ensure that potassium levels are within a safe range.
While monitoring glucose levels before and after meals is important for clients receiving insulin therapy, in this scenario, the primary concern is the elevated potassium level.
The nurse should prioritize frequent assessment of the serum potassium level to guide appropriate management and prevent complications associated with hyperkalemia.
Monitoring and documenting strict intake and output are important for assessing fluid balance and renal function, but in this case, the elevated potassium level takes precedence as it poses a more immediate risk to the client's well-being.
Obtaining a 12-lead electrocardiogram (ECG) daily may be indicated in some cases of hyperkalemia, as certain ECG changes can be associated with elevated potassium levels. However, the more critical aspect is monitoring the potassium level itself, as ECG changes can occur rapidly and may not always be detectable on a daily basis.
Correct Answer is B
Explanation
A) Incorrect- Anal abscesses and fistulas are more commonly associated with Crohn's disease than with ulcerative colitis. Crohn's disease can involve the entire thickness of the bowel wall and create tunnels or connections (fistulas) between different parts of the gastrointestinal tract.
B) Correct- Rectal bleeding is a common symptom of ulcerative colitis, as the inflamed tissue can bleed easily.
C) Incorrect- Constipation is not a common characteristic of Crohn's disease. In fact, both ulcerative colitis and Crohn's disease can lead to a range of bowel habits, including diarrhea and constipation, depending on the extent and location of inflammation.
D) Incorrect- Both ulcerative colitis and Crohn's disease are inflammatory bowel diseases (IBD) that involve chronic inflammation of the gastrointestinal tract. Ulcerative colitis primarily affects the colon and rectum, causing continuous areas of inflammation and ulceration. Crohn's disease can affect any part of the gastrointestinal tract, from the mouth to the anus. It often involves patches of inflammation with healthy tissue in between, and it can affect different layers of the bowel wall.
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