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

Bring a sterile chest drainage unit from central supply to the unit.

Evaluate a client's urinary catheter for proper drainage.

Call the pharmacy to obtain a client's next antibiotic dose.

Observe a client's gait to determine the need for assistance.

Answer and Explanation

The Correct Answer is A

A. Bring a sterile chest drainage unit from central supply to the unit: This task is appropriate for delegation to a UAP because it involves transporting equipment and does not require clinical judgment or assessment.

B. Evaluate a client's urinary catheter for proper drainage: This requires assessment skills to determine whether the catheter is functioning correctly or if complications such as obstruction or infection are present.

C. Call the pharmacy to obtain a client's next antibiotic dose: Communicating directly with the pharmacy about medications is part of the nurse’s responsibilities. It involves ensuring accuracy, safety, and proper coordination of care, which cannot be delegated to unlicensed staff.

D. Observe a client's gait to determine the need for assistance: While a UAP can walk with a client or provide basic support, determining the level of assistance needed requires assessment skills. Evaluating gait involves clinical judgment and must be performed by a licensed nurse or physical therapist.

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Correct Answer is ["A","B","C","D","E"]

Explanation

A. Complete blood count: A CBC is essential to evaluate hemoglobin and hematocrit levels, which can indicate the severity of blood loss from abdominal trauma. It also helps monitor for anemia or infection risk in this critical setting.

B. Arterial blood gas: An ABG provides information about oxygenation, ventilation, and acid–base balance, which are crucial for a trauma client on mechanical ventilation. It guides adjustments in ventilator settings and assesses for shock-related metabolic acidosis.

C. Type and screen: Given the evidence of internal bleeding and hypotension, a blood transfusion may be necessary. A type and screen ensures blood products can be matched and made available quickly in case of massive transfusion.

D. Coagulation studies: Trauma and massive transfusion can lead to coagulopathy. PT, INR, and aPTT results help guide interventions such as plasma or platelet administration, ensuring proper clotting function during surgery and recovery.

E. Electrolytes: Monitoring electrolytes is important because fluid resuscitation, blood loss, and shock can cause significant imbalances, such as hypokalemia or metabolic derangements, which can complicate management.

F. Blood culture: Blood cultures are obtained when infection or sepsis is suspected. This client’s presentation is acute trauma-related hemorrhage, not infection, so this test is not immediately useful.

G. Urine osmolality: This test is used to evaluate renal concentrating ability and fluid balance, but it is not a priority in acute trauma. Immediate fluid and blood replacement are the focus.

H. Lipid panel: A lipid panel assesses long-term cardiovascular risk, not acute trauma or hemorrhage. It has no role in the immediate plan of care for this client.

A. Argumentativeness and use of profanity. B. Periodic sighing and shaking the head. C. Decreased activity level and change in affect. D. Repeated requests for attention from the nurse.

Correct Answer is A

Explanation

A. Argumentativeness and use of profanity: These behaviors may indicate escalating agitation and a risk for violence. Monitoring for verbal aggression is essential because it can quickly progress to physical aggression, making safety the priority concern.

B. Periodic sighing and shaking the head: These are signs of frustration or discouragement but are less concerning than overt verbal aggression. They do not immediately signal a risk of harm to others.

C. Decreased activity level and change in affect: A decline in activity or affect may suggest depression or withdrawal but does not indicate an acute risk of violent escalation like pacing and scowling combined with verbal aggression.

D. Repeated requests for attention from the nurse: Frequent requests may reflect anxiety or dependency but do not typically indicate imminent aggression. While they should be addressed, they are not the most critical behaviors to monitor in this scenario.

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

Nursing Test Bank

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Correct Answer is A

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