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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Free Nursing Study Resources

Correct Answer is ["C","E","G"]

Explanation

A. IV site without redness or swelling: The IV site appears normal with no signs of infiltration or infection, so no immediate follow-up is required. This finding indicates proper IV insertion and maintenance.

B. Temperature: 98.8° F (37.1° C): This is within normal limits and does not indicate fever or infection, so it does not require immediate follow-up.

C. Respirations: 28 breaths/minute: This is above the normal adult range (12–20 breaths/minute) and may indicate respiratory distress due to pain, shallow breathing, or possible pulmonary complications such as atelectasis or pneumonia, requiring close monitoring and follow-up.

D. Heart rate: 92 beats/minute: Slightly elevated but within mild tachycardia range, which could be related to pain or anxiety. It should be monitored but does not require urgent follow-up.

E. Taking shallow breaths: Shallow breathing is concerning in a client with rib fractures, as it increases the risk for hypoventilation, atelectasis, and pneumonia. This requires immediate intervention, such as pain management and respiratory support.

F. Alert and oriented to person, place, time, and situation: Cognitive status is normal, so no follow-up is needed.

G. Pain 8 on a 0 to 10 scale: Severe pain limits deep breathing and mobility, increasing the risk of complications. Pain management should be addressed promptly to improve comfort and respiratory function.

H. Blood pressure: 138/82 mm Hg: Slightly elevated, likely related to pain or stress. Monitor trends, but it does not require immediate follow-up at this time.

A. Instruct to give additional dose if the baby vomits after administration. B. Demonstrate how to measure the correct amount of the oral solution. C. Notify the healthcare provider before giving digoxin if your baby is ill. D. Show the correct technique to obtain an apical pulse. E. Administer digoxin on a strict every 12-hour schedule.

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

Explanation

A. Instruct to give additional dose if the baby vomits after administration: Giving an extra dose after vomiting can result in digoxin toxicity because the exact amount absorbed is uncertain. Parents should never repeat a dose without consulting the healthcare provider.

B. Demonstrate how to measure the correct amount of the oral solution: Accurate measurement is critical for safe digoxin administration, as small errors can lead to underdosing or toxicity. Using an appropriate oral syringe or dropper ensures the correct dose.

C. Notify the healthcare provider before giving digoxin if your baby is ill: Illness can affect heart rate, hydration, and electrolyte balance, which increases the risk of digoxin toxicity. Parents should contact the provider to determine whether to hold or adjust the dose.

D. Show the correct technique to obtain an apical pulse: Digoxin can slow the heart rate. Parents should learn to assess the apical pulse for a full minute and understand the parameters for withholding medication based on heart rate guidelines.

E. Administer digoxin on a strict every 12-hour schedule: Maintaining consistent timing ensures stable blood levels, improving efficacy and reducing the risk of toxicity. A strict schedule is essential for therapeutic effectiveness.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse is reviewing the client's initial assessment findings. Which assessment findings require follow-up? Select all that apply.

Correct Answer is ["C","E","G"]

Explanation

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

Explanation

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