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This task is inappropriate for a UAP because assessing an IV site requires clinical judgment and knowledge of complications such as phlebitis, infiltration, or infection. Assessment is a nursing responsibility and cannot be delegated to unlicensed personnel. UAPs may observe and report changes, but they cannot be assigned to formally assess or interpret findings.

Helping a client ambulate every 2 hours requires careful consideration of the patient’s condition. While UAPs can assist with ambulation, the instruction here is too rigid and lacks assessment of the patient’s tolerance, safety, or risk factors. Ambulation schedules should be individualized and based on nursing assessment. Delegating this task without specifying safety precautions could place the patient at risk of falls or injury.

Explaining why a client cannot eat before surgery involves patient education, which requires nursing knowledge and professional communication. UAPs are not trained to provide preoperative teaching or explain medical rationales. This task requires a licensed nurse to ensure accurate information and address patient concerns. Delegating this to a UAP would be unsafe and outside their scope of practice.

This response is inappropriate because it assumes that being a family member automatically grants access to patient information. HIPAA requires explicit patient consent before sharing health details, regardless of family relationships. Providing information without permission violates confidentiality and could have legal consequences.

Transferring the call to the charge nurse does not solve the issue because the charge nurse is also bound by the same confidentiality rules. Without documented consent, no nurse can provide updates. This response may appear helpful but ultimately does not address the legal and ethical requirement to protect patient privacy.

This response is inappropriate because it discloses the patient’s condition (“stable”) without consent. Even minimal information is considered a breach of confidentiality. Additionally, promising to inform the patient of the call may create false expectations for the caller. This violates professional standards and patient rights.

This question reflects a misunderstanding. Negative pressure rooms are required for airborne precautions, such as tuberculosis, not droplet precautions. Droplet precautions involve preventing transmission of pathogens spread through large respiratory droplets, which typically travel short distances. Therefore, a negative pressure room is unnecessary, and asking this indicates confusion about the type of isolation.

While disposing of gloves and gowns after leaving the room is part of standard isolation practices, this question does not specifically demonstrate understanding of droplet precautions. It reflects general infection control knowledge rather than the unique requirement of droplet isolation, which centers on mask use.

Asking where extra masks are located shows awareness of supply management but does not demonstrate understanding of droplet precautions themselves. It focuses on logistics rather than the rationale for mask use. While important, it does not indicate comprehension of the specific protective measure required.

This option is incorrect because incident reports must be completed for all falls, regardless of whether the client is injured. Limiting reports to injured patients would omit important safety data and hinder quality improvement efforts.

Notifying the healthcare provider is necessary if the client sustained injuries or if there are concerns about their condition. However, since no serious injuries were noted, immediate provider notification is not required. Documentation and monitoring are the priority.

Assisting the client back to bed is appropriate for safety and comfort, but it is not the next best action after assessment. Documentation takes precedence to ensure the event is recorded and addressed within facility protocols.

This option is disrespectful and inappropriate. Referring to beliefs as “strange” is judgmental and dismissive, which can damage trust and rapport. Nurses must approach cultural assessment with sensitivity and respect.

Asking why the patient does not use electricity is intrusive and potentially offensive. It focuses on a stereotype rather than the patient’s individual needs. Cultural assessment should be patient-centered and avoid assumptions.

This option is inappropriate because it frames family involvement as an interruption rather than a supportive aspect of care. Amish culture often emphasizes family presence, and nurses should respect and accommodate this rather than view it negatively.

Checking for a carotid pulse for one full minute is inappropriate in an emergency because it delays initiation of CPR. Pulse checks should be brief to avoid wasting critical time.

Checking an apical pulse for 30 seconds is not appropriate in an unresponsive patient. Apical pulse assessment is used for routine monitoring, not emergency situations.

Counting the radial pulse for one full minute is inappropriate because radial pulses may be absent in cardiac arrest, and this delays life-saving interventions.

This is incorrect because CAUTIs can be prevented through evidence-based practices such as aseptic insertion, timely removal, and proper catheter care. Suggesting they cannot be prevented reflects poor understanding of infection control.

This is incorrect because CAUTIs increase, not decrease, the length of hospital stay. Infections prolong recovery and require additional treatment, leading to extended hospitalization.

This is incorrect because CAUTIs increase healthcare costs due to extended stays, additional treatments, and potential complications. Preventing CAUTIs reduces costs, but the primary reason for auditing is patient safety and complication reduction.

This action is correct because inserting two fingers under the restraint ensures that it is applied with appropriate tightness. Restraints should be snug enough to prevent removal but loose enough to allow circulation and prevent nerve damage. This practice reflects proper technique and patient safety awareness.

This action is correct because restraints must always be ordered by a licensed provider before application, except in emergencies where immediate safety is at risk. Obtaining an order demonstrates adherence to legal and ethical standards, as restraints are considered a last resort intervention.

This action is correct because restraints must be released at least every two hours to allow for range of motion, repositioning, toileting, and other patient needs. This prevents complications such as contractures, pressure injuries, and emotional distress. It also ensures the patient’s dignity and comfort are maintained.

This option is inappropriate because the client is non-verbal and cannot confirm their identity verbally. Asking them to state their birthday would not be effective in this situation.

This option is unsafe because room numbers are not reliable identifiers. Patients may be moved to different rooms, and relying on location can lead to misidentification and serious errors.

This option is inappropriate because relying on another nurse’s memory or familiarity is not a standardized or safe method of identification. Patient identification must be verified using official identifiers, not personal recognition.