Which task could a nurse delegate to unlicensed assistive personnel (UAP) assigned to a cardiac surgery unit?

Teaching a client how to use a pillow to support an incision when coughing.

Checking the pedal pulses of the bed-bound clients.

Ambulating the first-day postoperative clients.

Emptying the urine drainage bags at least once per shift.

Answer and Explanation

The Correct Answer is D

Emptying the urine drainage bags at least once per shift is a task that can be delegated to unlicensed assistive personnel (UAP) assigned to a cardiac surgery unit.

This task does not require assessment, teaching, or evaluation skills that are beyond the scope of practice of UAP.

Choice A is wrong because teaching a client how to use a pillow to support an incision when coughing requires education and evaluation skills that are only within the scope of practice of licensed nurses.

Choice B is wrong because checking the pedal pulses of bed-bound clients requires assessment skills that are only within the scope of practice of licensed nurses.

Pedal pulses are important indicators of peripheral circulation and vascular status.

Choice C is wrong because ambulating the first-day postoperative clients requires assessment and evaluation skills that are only within the scope of practice of licensed nurses.

First-day postoperative clients may have complications such as bleeding, infection, or hypotension that need to be monitored by a nurse.

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Correct Answer is B

Explanation

This is because itching is a subjective assessment finding, which means it is based on the personal experience, view or feeling of the

patient. The other choices are objective assessment findings, which means they are based on observable or measurable data that the nurse can collect.

For example:

Choice A is wrong because hives are a visible skin reaction that can be seen and measured by the nurse.

Choice C is wrong because vomiting is an observable action that can be verified and recorded by the nurse.

Choice D is wrong because abdominal distension is a measurable change in the size or shape of the abdomen that can be assessed by the nurse.

Normal ranges for objective assessment findings may vary depending on the source and context, but some possible examples are:

Hives: No hives or rashes on the skin are normal.
Vomiting: No vomiting or nausea are normal.
Abdominal distension: Normal abdominal girth for adults ranges from 68 to 100 cm (27 to 40 inches).

A. Increased heart rate. B. Decreased blood pressure. C. Increased temperature. D. Hypoactive muscle responses. E. Alert and oriented.

Correct Answer is ["A","B"]

Explanation

Increased heart rate and decreased blood pressure are common signs of dehydration, as the body tries to compensate for the fluid loss by increasing the heart rate and lowering the blood pressure.

Choice C is wrong because increased temperature is not a typical symptom of dehydration, although it can be a cause of it.

Choice D is wrong because hypoactive muscle responses are not related to dehydration, but rather to neurological or muscular disorders.

Choice E is wrong because alert and oriented is the normal mental status for most people, and dehydration can cause confusion and disorientation in severe cases.

Normal ranges for heart rate and blood pressure vary depending on age, gender, physical activity, and other factors, but generally they are:

Heart rate: 60 to 100 beats per minute for adults
Blood pressure: less than 120/80 mmHg for adults

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Which task could a nurse delegate to unlicensed assistive personnel (UAP) assigned to a cardiac surgery unit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of these assessment findings should a nurse record as subjective?

Correct Answer is B

Explanation

A middle-aged adult client with nausea and vomiting for three days presents to the emergency room. Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.

Correct Answer is ["A","B"]

Explanation

An 82-year-old client was admitted to the hospital on isolation precautions 3 days ago for C diff. The client begins to demonstrate irritability, confusion, and paranoia. Which of the following is the best reason for the assessment findings?

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The nurse knows that documentation should record the interventions and the care given to the client. What is the rationale?