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.

Answer and Explanation

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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Correct Answer is A

Explanation

A) Correct- Hematocrit values below the reference range during pregnancy could indicate anemia, which requires further evaluation and intervention. The other findings can be attributed to normal physiological changes during pregnancy (elevated total T4, heart rate increase) or can be common findings (systolic murmur).
B) Incorrect - A heart rate of 92 beats per minute is within the normal range for pregnancy due to increased blood volume and hormonal changes.
C) Incorrect - A systolic murmur can be a common finding during pregnancy due to increased cardiac output.
D) Incorrect - An elevated total T4 can be a normal finding during pregnancy due to hormonal changes.

A. Provide a printed health care assessment form. B. Defer the health history until the client is less anxious. C. Ask the family member to answer the questions. D. Assess the surroundings for noise and distractions.

Correct Answer is D

Explanation

The ability to effectively communicate and provide accurate information can be impacted by external factors such as noise, distractions, or an unfamiliar environment. By assessing the surroundings, the nurse can identify and address any potential barriers to communication.

Once the nurse has addressed any environmental factors that may be hindering communication, they can proceed with other strategies to facilitate the health history assessment. This may include providing a printed healthcare assessment form to assist the client in organizing their thoughts or deferring the assessment until the client is less anxious.

Asking the family member to answer the questions should be considered if the client is unable to provide accurate information or is cognitively impaired. However, it is important to first address any environmental factors and attempt to engage the client directly in the assessment process.

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Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?

Correct Answer is D

Explanation

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