assignment/ delegation

The registered nurse (RN) on a medical-surgical unit is working with a licensed practical nurse (LPN) and unlicensed assistive personnel (UAP). Which tasks are most appropriate to assign to the LPN? Select all that apply. 1. Administering a scheduled analgesic to a client with chronic back pain currently rated 8/10 2. Assessing fluid volume status of a client with heart failure who is scheduled for discharge 3. Assisting with bathing, feeding, and dressing a client with multiple sclerosis 4. Performing wound care and sterile dressing change for a client with a stasis ulcer 5. Providing incontinence care and linen change for a client with diarrhea

1. Administering a scheduled analgesic to a client with chronic back pain currently rated 8/10 4. Performing wound care and sterile dressing change for a client with a stasis ulcer Wound care and routine medication administration are the most appropriate tasks to assign to the LPN. The LPN can perform sterile procedures and cleanse and dress wounds for which there is an established prescription plan (Option 4). Pain rated at 8/10 is an expected finding in a client with chronic back pain, and the oral analgesic may be administered as scheduled by the LPN (Option 1). If this client were experiencing new-onset, unexplained pain requiring intravenous analgesic administration, the client would need assessment by the RN. (Option 2) The LPN may perform specific assessments, but evaluating the fluid volume status of a heart failure client is a comprehensive assessment involving multiple body systems (eg, heart and lung sounds, peripheral edema, adequacy of urine output). This client will also require discharge education on home management of heart failure, which is the responsibility of the RN. (Options 3 and 5) UAP have the appropriate skills and knowledge to meet clients' elimination, hygiene, and comfort needs. Although these tasks could be safely carried out by an LPN, underutilizing UAP would be an ineffective use of resources.

The registered nurse (RN) and practical nurse (PN) are caring for a client who was admitted to the medical unit last night with a moderate asthma exacerbation and an upper respiratory infection. Which tasks are appropriate for the RN to delegate to the PN? Select all that apply. 1. Administering albuterol metered-dose inhaler medication 2. Auscultating lung sounds to determine the response to a bronchodilator 3. Checking oxygen saturation with the pulse oximeter 4. Measuring morning peak expiratory flow with the client's peak flow meter 5. Teaching the client about a newly prescribed inhaled corticosteroid

1. Administering albuterol metered-dose inhaler medication 3. Checking oxygen saturation with the pulse oximeter 4. Measuring morning peak expiratory flow with the client's peak flow meter When delegating tasks, the registered nurse (RN) should consider the 5 rights of delegation along with the scope of practice. The scope of practice for a practical nurse (PN) includes administering medications, although regulations related to narcotics and IV medications vary by state (Option 1). Based on staff member availability, it can also be appropriate to perform or delegate tasks below the scope of a given staff member (eg, delegating vital signs to a PN, an RN performing ostomy care) (Option 3). Measuring peak expiratory flow with a peak flow meter is also within the scope of practice for a PN (Option 4). (Option 2) The PN can collect data (eg, auscultating breath sounds, observing for accessory muscle use). However, evaluation of the collected data (ie, determining the client's response to a bronchodilator medication) is the responsibility of the RN, as it requires use of the nursing process. (Option 5) PNs are able to reinforce education initiated by the RN. However, providing teaching on new topics may not be delegated to the PN. Educational objective:Administering most medications and collecting data related to adequacy of oxygenation and ventilation are tasks within the scope of practice for a licensed practical nurse. The overall assessment, analysis, and evaluation of the collected data to develop the client plan of care are the responsibilities of the supervising registered nurse.

A registered nurse (RN), a licensed practical nurse (LPN), and unlicensed assistive personnel are caring for a client who is 1-day postoperative gastric bypass surgery. Which pain management-related tasks should the RN delegate to the LPN? Select all that apply. 1. Administering oral pain medication 2. Assessing characteristics of pain 3. Measuring vital signs before and after analgesic administration 4. Monitoring pain level using a numeric scale 5. Providing discharge teaching about pain management

1. Administering oral pain medication 4. Monitoring pain level using a numeric scale Everyone on the health care team contributes to the client's pain management. The registered nurse (RN) is responsible for developing the pain management care plan, which includes assessing subjective characteristics of pain (ie, P - provocation/palliation, Q - quality, R - region/radiation, S - severity, T - timing); performing initial client and caregiver teaching, including discharge instructions; and evaluating the effectiveness of the care plan (Options 2 and 5). The nurse should always consider the 5 rights of delegation prior to delegating a task. In this case, the RN may delegate the following tasks to the licensed practical nurse (LPN): Administering oral pain medication; individual practice region and facility policy will determine which of the various routes of medication the LPN is permitted to use (Option 1) Monitoring current objective pain level (numeric scale) (Option 4) (Option 3) The RN should delegate vital sign measurement to the unlicensed assistive personnel (UAP). Although vital sign measurement is within the LPN's scope of practice, delegating this task to UAP is a more efficient use of resources. The RN should provide instructions regarding timing of vital sign measurement and is responsible for evaluating the client's vital signs. Educational objective:The registered nurse is responsible for assessing pain characteristics, developing the care plan, and providing initial and discharge teaching. A licensed practical nurse may monitor pain level and administer pain medication. The nurse should consider the 5 rights of delegation and effective use of resources when delegating tasks.

Which tasks can the registered nurse safely delegate to unlicensed assistive personnel? Select all that apply. 1. Ambulate an oxygen-dependent client to the bathroom 2. Assist client with dentures to perform oral suctioning after the client's meal 3. Document pulse oximetry of a client with chronic obstructive pulmonary disease 4. Instruct a client with pneumonia on use of the incentive spirometer 5. Turn and reposition a client with pneumonia

1. Ambulate an oxygen-dependent client to the bathroom 2. Assist client with dentures to perform oral suctioning after the client's meal 3. Document pulse oximetry of a client with chronic obstructive pulmonary disease 5. Turn and reposition a client with pneumonia Unlicensed assistive personnel (UAP) may assist stable clients with activities of daily living, hygiene needs, ambulation, and turning and repositioning. UAP may also collect and record vital signs (eg, pulse oximetry); obtain and set up equipment; and take precautions to prevent aspiration (eg, oral care and suctioning). When delegating to UAP, the registered nurse (RN) clearly defines the task, time frame for completion, and expected outcomes (eg, report client's difficulty breathing, tolerance of procedures, results of vital sign measurements). Furthermore, the RN should be certain that all UAP demonstrate competency and have been validated in all delegated tasks. The RN can safely delegate these tasks to UAP: Ambulate and promote mobility of stable clients (Option 1) Assist with activities of daily living (eg, feeding, bathing, dressing, hygiene) Perform oral (nonsterile) suctioning for clients during oral care (Option 2) Collect and document vital signs (Option 3) Turn and reposition stable clients (Option 5) (Option 4) Although UAP can assist clients in using an incentive spirometer, the RN is responsible for client teaching about appropriate use. Educational objective:Unlicensed assistive personnel can safely assist stable clients with activities of daily living, hygiene needs, ambulation, and repositioning. They can also collect and document vital signs (eg, pulse oximetry) and use aspiration precautions (eg, oral hygiene and suctioning). The registered nurse is responsible for client teaching, ongoing assessment, and evaluation of outcomes.

The unit is staffed with an experienced registered nurse, an experienced licensed practical nurse, and unlicensed assistive personnel (UAP). Which tasks can the charge nurse appropriately delegate to UAP? Select all that apply. 1. Apply protective skin ointment after perineal cleansing 2. Determine if a client has adequate relief after administration of an analgesic 3. Document daily weight for a client with congestive heart failure 4. Feed a client who had a stroke 24 hours after admission 5. Perform passive range-of-motion exercises for a client on a ventilator

1. Apply protective skin ointment after perineal cleansing 3. Document daily weight for a client with congestive heart failure 5. Perform passive range-of-motion exercises for a client on a ventilator Unlicensed assistive personnel (UAP) are assigned tasks for stable clients by the registered nurse (RN), who directs and manages overall client care. The RN cannot delegate the nursing process. UAP can perform active and passive range-of-motion exercises (Option 5). Under the direction of the RN, UAP can apply protective ointment (such as zinc oxide) after cleaning a client (Option 1). UAP can obtain data but the RN is responsible for interpreting (evaluating) it. For example, UAP can obtain objective data such as the client's height and weight, but the RN will analyze this data to determine the need in the nursing care plan (eg, effect on drug dosing) (Option 3). (Option 2) UAP can collect data (eg, an objective pain score), but the RN is responsible for evaluating if the relief is adequate. The word "adequate" refers to the evaluation of treatment and is not part of UAP scope of practice. The RN may consider other aspects (eg, vital signs, body language) when making such evaluations, especially in a nonverbal client. (Option 4) A stroke is not considered stabilized until approximately 48 hours have passed without changes. The client's risk of losing the gag reflex is still high as the stroke could be evolving. UAP should feed only stable clients.

It is the first day on the job for the newly hired unlicensed assistive personnel (UAP). Which of these illustrate appropriate delegation instructions for the registered nurse (RN) to give the UAP? Select all that apply. 1. "Elevate the right leg on two pillows." 2. "Measure client for compression stockings." 3. "Please let me know what the urine looks like." 4. "Tell me what the client eats at lunch." 5. "Verify wrist restraints are on correctly.

1. "Elevate the right leg on two pillows." 4. "Tell me what the client eats at lunch." Directions to the unlicensed assistive personnel (UAP) should be for tasks (versus total client responsibility) with specific and explicit requirements versus those requiring analysis/judgment/evaluation (the nursing process). Elevate leg on 2 pillows is very specific and does not require specialized knowledge or skill (Option 1). Report what the client eats at lunch is data collection only (Option 4). The RN will analyze the data to see if the amount of food is adequate. (Option 2) The UAP may apply compression stockings or devices, but the RN or LPN should measure the client to choose the appropriate size as this is beyond the UAP's scope of practice. (Option 3) This involves an assessment that the RN should perform. The RN could ask for specific data, such as amount of urine or presence of blood clots. (Option 5) This requires a judgment (is the restraint tight enough/too tight and causing impaired circulation?) that the RN should make. The UAP could be assigned a specific task, such as offering a drink to the client. Educational objective:Assign a new UAP specific tasks that do not require specialized knowledge or skills. The UAP can gather data but should not be asked to assess/analyze/evaluate or measure client for compression devices.

The nurse is delegating client care tasks to a licensed practical nurse (LPN) and unlicensed assistive personnel. Which of the following assignments are most appropriate to assign to the LPN? Select all that apply. 1. Administer a client's daily dose of subcutaneous insulin glargine 2. Administer a scheduled oral analgesic to a 2 days postoperative client 3. Complete an admission nursing interview for a client admitted for elective hysterectomy 4. Reinforce teaching on self-administration of insulin to a client with diabetes mellitus 5. Tally the shift's intake and outputs for the entire unit

1. Administer a client's daily dose of subcutaneous insulin glargine 2. Administer a scheduled oral analgesic to a 2 days postoperative client 4. Reinforce teaching on self-administration of insulin to a client with diabetes mellitus Nurses preparing to delegate client care to a licensed practical nurse (LPN) and/or unlicensed assistive personnel (UAP) should consider the 5 rights of delegation. The LPN can monitor and care for stable clients who have been initially evaluated by a registered nurse (RN). Interventions LPNs may perform include: Administering oral and parenteral medications, but excluding administering IV medications, which vary by state legislation (Options 1 and 2) Reinforcing teaching and skills that have been initially taught by the RN (Option 4) Focused assessments (eg, bowel sounds) after the RN's initial assessment (Option 3) Performing admission or initial assessments is outside the scope of the LPN and UAP. The RN must perform initial assessments in order to analyze the findings and formulate the client's plan of care before delegating tasks. (Option 5) The LPN is capable of performing routine care (eg, calculating daily intake and output, toileting). However, the UAP may also perform these tasks, which frees the LPN to perform more complex duties. Therefore, the most appropriate staff member to assign the task of calculating intake and output to is the UAP.

The registered nurse is working with a licensed practical nurse and unlicensed assistive personnel. A client has just returned to the cardiac unit after a percutaneous coronary intervention. Which actions are most appropriate for the registered nurse to assign to the licensed practical nurse? Select all that apply. 1. Administer oral pain medication for the client's chronic lower back pain 2. Assist the client with the use of a urinal post-procedure 3. Monitor for bleeding at the catheter insertion site every 15 minutes 4. Perform the initial post-procedure vital sign measurements 5. Review the ECG monitor for dysrhythmias

1. Administer oral pain medication for the client's chronic lower back pain 3. Monitor for bleeding at the catheter insertion site every 15 minutes After performing the initial assessment of the client post-procedure and comparing it to the pre-procedure baseline, the registered nurse (RN) may assign the following tasks to the licensed practical nurse (LPN):Administer medications (Option 1)Monitor neurovascular status of involved extremityMonitor for bleeding at catheter site every 15 minutes for the first hour, then according to facility policy (Option 3)Report any changes in neurovascular status or bleeding to the RN(Option 2) Unlicensed assistive personnel (UAP) possess appropriate skills and knowledge to meet clients' elimination, hygiene, and comfort needs. Although these tasks could be performed safely by an LPN, underutilizing UAP would be an ineffective use of resources.(Options 4 and 5) The RN should perform initial assessments (including vital signs), review the ECG for any dysrhythmias, monitor the client for chest pain, and monitor any infusions of anticoagulants or antiplatelet drugs. If the client is stable after the initial assessment, the RN may delegate routine vital sign measurements to the UAP.Educational objective:In the client who has had a percutaneous coronary intervention, after initial assessment and comparison to pre-procedure baseline, the RN may assign the tasks of medication administration, monitoring of neurovascular status of the involved extremity, and checking for bleeding at the catheter insertion site to the LPN.

A nurse delegates a task to the unlicensed assistive personnel (UAP). The UAP states, "I can't do that." Which is the best initial response for the nurse to make? 1. Ask the UAP the reason for the response. 2. Do the task, but discuss the UAP's response with the manager. 3. Ignore the UAP's initial response and repeat the delegation request. 4. Remind the UAP of the importance of teamwork.

1. Ask the UAP the reason for the response. Just as in clinical situations, the nurse should first assess in management situations. The UAP may not have the skills or abilities to do the task or the availability if doing something else. The nurse may need to reprioritize the tasks that the UAP has been delegated or provide additional instructions/education. However, finding out the reason for the response is the first step. (Option 2) This does not solve the issue. The RN does not have the time to do everything, which is the reason for delegating. Speaking to the manager is an appropriate response if there is a pattern of insubordination or refusals, such as when the UAP is capable, not busy, and yet does not respond to the nurse's encouragement to help out. (Option 3) It is important to find out the reason for the response to ensure client safety and completion of the task. A repeat request would be more appropriate if the UAP did not indicate a response (maybe the UAP didn't hear or understand) or gave an inappropriate response (eg, not my team). (Option 4) This response is more appropriate if the UAP has the ability and availability but is citing something else for the refusal, such as the task not belonging to the UAP's assigned team. Assessment for the reason should be first.

The nurse is caring for a client in soft wrist restraints. Which tasks can the nurse safely delegate to the unlicensed assistive personnel? Select all that apply. 1. Assist the client with using a bedpan 2. Check pulses and sensation of extremities 3. Observe skin for signs of impairment 4. Perform range-of-motion exercises 5. Turn and reposition the client in bed

1. Assist the client with using a bedpan 4. Perform range-of-motion exercises 5. Turn and reposition the client in bed Nurses may delegate to unlicensed assistive personnel tasks that relate to basic hygiene; tasks of daily living; measurement and documentation of vital signs and intake and output; and validated technical skills. Activities requiring assessment may be performed only by the nurse. Delegating care to unlicensed assistive personnel (UAP) requires understanding of both body policies and staff member training. UAP may assist with care of stable clients related to tasks of basic hygiene (eg, bathing, toileting) and daily living (eg, feeding, positioning, range-of-motion exercises); measurement and documentation of vital signs and intake and output; and technical skills (eg, capillary blood glucose monitoring, IV catheter removal) with appropriate training (Options 1, 4, and 5). Assurance of appropriateness and completion of delegated tasks remain the duty of the nurse. (Options 2 and 3) When physical restraints are applied to a client, the nurse is responsible for the primary and ongoing assessments (eg, skin integrity, peripheral pulses, neurovascular status), determining appropriateness of restraint type, need for continued use, and psychological response. These tasks may not be delegated to the UAP. The UAP may report changes in these areas if noted but must not be expected to monitor for changes.

Which tasks can the registered nurse appropriately delegate to unlicensed assistive personnel? Select all that apply. 1. Assist the registered nurse with ambulating a client 1-day post chest tube placement 2. Measure wound drainage from a bulb drain and document it on the output flow sheet 3. Monitor for redness and swelling at the IV insertion site and report back to the nurse 4. Return an unused unit of packed red blood cells to the blood bank 5. Take family members to the waiting room after the client goes into surgery

1. Assist the registered nurse with ambulating a client 1-day post chest tube placement 2. Measure wound drainage from a bulb drain and document it on the output flow sheet 4. Return an unused unit of packed red blood cells to the blood bank 5. Take family members to the waiting room after the client goes into surgery Unlicensed assistive personnel (UAP) may perform routine tasks for stable clients under the direction of the registered nurse (RN). Tasks related to the nursing process (eg, assessment, planning, evaluation) require trained knowledge, critical thinking, and individualized application by the RN and cannot be delegated. A client 1-day post chest tube placement must be assessed by the RN to establish safety and readiness for ambulation. However, the UAP can assist the RN in ambulating if appropriate (Option 1). UAP can empty, measure, and record output from a surgical drain. However, the RN is responsible for assessing the drainage (eg, type, amount, odor, color) and maintaining the wound drainage device (Option 2). As directed by the RN, UAP can courier blood products to and from the blood bank (Option 4). However, verification of any blood products must be performed by 2 RNs prior to transfusion. UAP can carry out comfort measures such as escorting family members to the waiting area (Option 5). (Option 3) Although UAP may report observations of abnormal physical signs to the nurse, it is the RN's responsibility to assess the client's ongoing condition. Monitoring of RN findings can be delegated to a licensed practical nurse but not to a UAP. Educational objective:Unlicensed assistive personnel may perform clerical (eg, escorting family members, transporting blood products) and clinical tasks (eg, emptying, measuring, and recording output) related to the care of stable clients under the direction of the reg

The registered nurse (RN) is working with unlicensed assistive personnel (UAP). Which task can the RN safely delegate to the UAP? 1. Assisting a 2-day postoperative hip arthroplasty client with morning care 2. Collecting a urine specimen for culture and sensitivity from a client with a Foley catheter 3. Initial change of colostomy bag for a client who is 1-day postoperative colostomy 4. Refilling the empty enteral feeding container with tube feeding

1. Assisting a 2-day postoperative hip arthroplasty client with morning care The RN should always observe the 5 rights of delegation when considering appropriate task assignments. Bathing along with mouth and skin care are standardized, routine procedures. Therefore, the RN can delegate to the UAP the task of assisting the 2-day postoperative client with morning care. A client who is 2-days postoperative hip arthroplasty is usually stable, but the nurse can reassess the delegated tasks if the client's condition changes. (Option 2) Specimen collection from a Foley catheter is considered a sterile procedure. It involves accessing a sterile collection port, but there is a risk of introducing bacteria into the closed drainage system if done improperly. However, the UAP or even the client may collect a clean-catch or midstream urine specimen when appropriate instructions are given. (Option 3) Changing the colostomy bag for a client with an established stoma (not fresh) can be delegated by the RN to the UAP. However, the RN must first assess the appearance and function of the new colostomy stoma during the initial bag change. This requires nursing knowledge and judgment. The RN is also responsible for providing both initial client education regarding the new colostomy and emotional support as many clients have difficulty adjusting to the change in body image. (Option 4) The RN does not delegate care related to enteral feedings to the UAP as this requires professional nursing skills regarding abdominal and placement assessment, aspiration of residual volumes, and irrigation. Educational objective: The UAP with the skills and knowledge can perform standardized procedures (eg, assisting a client with morning care, emptying a colostomy bag in a client with an established stoma). However, UAP are not responsible for sterile proc

The charge nurse in a long-term memory care facility is making assignments for the Alzheimer unit. Which tasks may be delegated to experienced unlicensed assistive personnel? Select all that apply. 1. Assisting clients with bathing and hair care 2. Evaluating safety hazards in clients' rooms 3. Monitoring clients for behavioral changes 4. Placing bed alarms at night for clients at risk for wandering 5. Reporting swallowing difficulties of a client during mealtime

1. Assisting clients with bathing and hair care 4. Placing bed alarms at night for clients at risk for wandering 5. Reporting swallowing difficulties of a client during mealtime Many clients with advanced Alzheimer disease reside in long-term care centers; therefore, most routine care activities can be delegated to the licensed practical nurse (LPN) and unlicensed assistive personnel (UAP). The role of the LPN includes: Administration of enteral feedings (if prescribed) Administration of medications Monitoring for safety hazards Monitoring for behavioral changes The role of UAP includes: Assisting with activities of daily living (eg, toileting, bathing, skin care, oral care, personal hygiene) (Option 1) Assisting with feeding Reporting changes in ability to eat or difficulty swallowing (Option 5) Reporting changes in behavior Placing bed alarms to reduce risk of falls (Option 4) (Option 2) UAP may be directed by a nurse to remove or alter safety hazards in a client's room, but the nurse retains the responsibility of evaluating the environment. (Option 3) The UAP may report changes in client behavior to the nurse. The LPN can monitor for behavioral changes, and the RN can develop strategies to address difficult behavior. Educational objective:While caring for a client with Alzheimer disease, the licensed practical nurse is responsible for administration of medications and enteral feedings (if prescribed) and monitoring for safety hazards and behavioral changes. The role of unlicensed assistive personnel involves helping with activities of daily living and reporting changes in the client.

The registered nurse (RN) is caring for a postoperative client who becomes short of breath on the night of surgery and initiates the prn prescription for oxygen at 3 L/min by nasal cannula. The client makes frequent requests to use the bathroom during the night. Which tasks can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Assisting the client to the bathroom 2. Deciding if supplemental oxygen is necessary when the client is ambulating 3. Documenting vital signs in the electronic medical record 4. Notifying the nurse immediately if the client's respirations exceed 20/min 5. Reapplying the nasal cannula if it accidentally comes off

1. Assisting the client to the bathroom 3. Documenting vital signs in the electronic medical record 4. Notifying the nurse immediately if the client's respirations exceed 20/min 5. Reapplying the nasal cannula if it accidentally comes off Before assigning any task, the RN must assess the competency level of the UAP. The RN must review proper safety principles when using an oxygen delivery device and the procedure for reapplication of a nasal cannula before assigning the task. Meeting hygiene and elimination needs, documenting observations made during usual care (eg, shortness of breath) in the section of the medical record designated for the UAP, taking vital signs, and reapplying an oxygen delivery device (cannula) at the preset liter flow are tasks appropriate for an experienced UAP. However, any abnormal finding, such as shortness of breath, or change in vital signs (eg, respirations greater than 20/min), must be validated and assessed by the RN. (Option 2) Deciding whether the client needs supplemental oxygen via an oxygen tank when ambulating to the bathroom requires assessment by the RN.

The postpartum nurse receives report on 4 mother-baby couplets. Which tasks can be delegated to unlicensed assistive personnel? Select all that apply. 1. Assisting the mother with morning hygiene 2. Demonstrating neonate bathing technique 3. Documenting intake and output on the mother 4. Evaluating caregiver interaction with the neonate 5. Obtaining an axillary temperature on the neonate 6. Swaddling the neonate after diaper changes

1. Assisting the mother with morning hygiene 3. Documenting intake and output on the mother 5. Obtaining an axillary temperature on the neonate 6. Swaddling the neonate after diaper changes Assisting clients with activities of daily living is within the scope of practice of unlicensed assistive personnel (UAP). Helping the mother with morning hygiene, documenting intake and output, taking vital signs of stable clients, and swaddling the neonate may be delegated to UAP. The registered nurse (RN) should follow the 5 rights of delegation when planning care. (Option 2) The RN assumes responsibility for initial client teaching and demonstration of home care. Once teaching and demonstration are complete, the UAP can assist the mother with bathing the neonate. (Option 4) The RN should assess caregiver interaction with the newborn to identify any attachment issues. Elements of the nursing process (assessment, planning, and evaluation) and tasks requiring nursing judgment cannot be delegated. Educational objective:The registered nurse is responsible for any care requiring clinical judgment. Unlicensed assistive personnel can assist with activities of daily living, documenting intake and output, positioning, and taking the vital signs of stable clients.

The nurse supervisor tells the psychiatric nurse to go to the telemetry unit ("float") as the unit is short staffed and has 2 clients with cardiac arrest. The nurse is not familiar with this client population and does not want to go. What is the best response by the psychiatric nurse? 1. Clarify the skills/knowledge that the nurse is able/unable to perform. 2. Read the policy and procedure book for the unit before providing care. 3. Refuse to go due to concerns about client safety 4. Tell the supervisor to send someone else instead.

1. Clarify the skills/knowledge that the nurse is able/unable to perform. When asked to "float" to help out in another unit, the nurse should clarify the duties to be performed. Many skills/knowledge, such as vital signs and routine medication administration, are the same in all units. The nurse should be given a unit orientation. The nurse should then clarify applicable skills. For instance, the nurse could perform basic care but not feel comfortable watching the telemetry cardiac monitors or assisting with insertion of a pacemaker. These limitations are usually understood and respected. The qualified and experienced registered nurses on the unit perform specialized client needs, and the "float" nurse performs basic client needs. The nurse is liable to provide safe care for the assigned duties and perform them in a competent manner. The nurse should personally document any concerns raised with the supervisor and avoid discussing personal feelings about the "float" with clients or other staff. (Option 2) There will be neither time nor need to read an entire policy book on specialized care. (Option 3) There is legal precedence that refusal to go when asked to "float" can result in disciplinary action. Options in which the nurse can provide safe care rather make an across-the-board refusal should be explored. The hospital is required to provide safe care and is liable if a unit is insufficiently staffed. (Option 4) This would be considered a refusal. The supervisor probably has considered options (eg, staff in other units) and has chosen this nurse. If a more qualified individual was available, the supervisor probably would have already sent this person. Educational objective:When a nurse is asked to care for clients in an unfamiliar population ("float"), the duties to be performed and the nurse's limitations in skills

A registered nurse (RN), licensed practical nurse (LPN), and unlicensed assistive personnel are working on the unit. A client who is about to be discharged home with tube feedings needs care. Which responsibilities should the RN delegate to the LPN? Select all that apply. 1. Cleaning the skin surrounding the gastrostomy tube stoma 2. Crushing and administering metoprolol through the gastrostomy tube 3. Programming the feeding pump to administer a prescribed bolus feeding 4. Teaching the client about home enteral feeding and gastrostomy tube care 5. Weighing the client using the bed scale

1. Cleaning the skin surrounding the gastrostomy tube stoma 2. Crushing and administering metoprolol through the gastrostomy tube 3. Programming the feeding pump to administer a prescribed bolus feeding

The charge nurse on the telemetry unit is making client assignments. Which client is appropriate to assign to the licensed practical nurse (LPN)? 1. Client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void 2. Client being discharged after deep vein thrombosis who needs teaching on how to self-administer enoxaparin injections 3. Client who has just been admitted to the telemetry unit from the emergency department with a rule-out myocardial infarction 4. Client with a nitroglycerin infusion with prescription to titrate to keep systolic blood pressure <150 mm Hg; currently is 110/62 mm Hg

1. Client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void IncorrectCorrect answer 1 Collecting Statistics 84%Answered correctly 37 secsTime Spent 12/06/2020Last Updated Other Possible Answers The charge nurse should assign the most stable and predictable client to the LPN. The client who needs to have a urinary catheter reinserted is within the scope of practice for the LPN. The other clients need nursing interventions that require independent nursing knowledge, skill, and judgment such as assessment, client teaching, and evaluation of care. (Option 2) The registered nurse (RN) is responsible for initial client teaching. Teaching self-administration of enoxaparin can be complex and should be done by the RN. The LPN can reinforce the teaching done by the RN. (Option 3) The client being admitted from the emergency department requires clinical assessment and clinical judgment, which should be handled by the RN. (Option 4) The client on nitroglycerin is complex and requires titration of an intravenous medication; this client should be assigned to an RN.

The nurse is caring for a client who needs an indwelling urinary catheter inserted for urinary retention. Which tasks would be appropriate to delegate to the unlicensed assistive personnel? Select all that apply. 1. Document output from the urinary collection bag 2. Hold adipose tissue out of the way during catheter insertion 3. Monitor color of the urine after the nurse has assessed it 4. Reinforce education about the purpose of the urinary catheter 5. Secure the catheter to the client's thigh with an anchor

1. Document output from the urinary collection bag 2. Hold adipose tissue out of the way during catheter insertion 5. Secure the catheter to the client's thigh with an anchor It is within the unlicensed assistive personnel (UAP) scope of practice to document output from a urinary collection bag (Option 1). The UAP can assist the nurse during a procedure by helping to position a client or holding part of the client's body (Option 2). The UAP may also perform routine tasks, such as securing a catheter to the client's thigh with an anchor device (Option 5). (Option 3) A licensed practical nurse (LPN) may monitor for changes after an initial assessment has been performed by a registered nurse (RN), but this is not within the UAP scope of practice. (Option 4) Education should be provided by the RN. Reinforcement of education may be performed by the LPN, but it is not within the UAP scope of practice. Educational objective:Unlicensed assistive personnel (UAP) cannot provide client education, perform assessments, or monitor for assessment changes. UAP should not be delegated tasks outside their scope of practice.

The nurse is assigned to care for clients with assistance from unlicensed assistive personnel (UAP). Which of the following tasks are appropriate for the nurse to assign to UAP? Select all that apply. 1. Emptying a urinary drainage bag and recording output volume 2. Emptying and verifying the patency of an accordion drain 3. Escorting a disgruntled family member off the unit 4. Providing perineal care around an indwelling urinary catheter 5. Reapplying bilateral sequential compression devices

1. Emptying a urinary drainage bag and recording output volume 4. Providing perineal care around an indwelling urinary catheter 5. Reapplying bilateral sequential compression devices To delegate a task appropriately, the nurse must observe the 5 rights of delegation to ensure that the skills and experience required for performing the task are adequate and are within the delegatee's scope of practice. Unlicensed assistive personnel (UAP) can perform basic tasks that require little assessment and are unlikely to cause harm to the client. Obtaining a clean-catch urine specimen, emptying a urinary drainage bag, providing perineal care around an indwelling urinary catheter, and reapplying sequential compression devices are all routine tasks that can be safely performed by UAP (Options 1, 4, and 5). (Option 2) UAP can measure, empty, and document the output of a drain, but the registered nurse is responsible for assessing proper drain function and the type, amount, color, and odor of drainage. (Option 3) With a disgruntled family member, there may be a need for skilled communication to keep the situation from escalating. The visitor should be escorted off the unit by a security officer.

A client is hospitalized for a broken leg. The client has a history of breast cancer and is receiving outpatient chemotherapy; the last infusion was about a week ago. Which staff members can safely care for this client? Select all that apply. 1. Nurse floated from another medical-surgical floor 2. Nurse who is 24 weeks pregnant 3. Nurse with erythematous rash and honey-color crusts on the hand 4. Unlicensed assistive personnel who just received the yearly injectable flu vaccination 5. Unlicensed assistive personnel with a cold

1. Nurse floated from another medical-surgical floor 2. Nurse who is 24 weeks pregnant 4. Unlicensed assistive personnel who just received the yearly injectable flu vaccination A client who has recently received chemotherapy may be immunocompromised and should be protected from infectious contacts. Infectious contacts include staff members with a cold or impetigo, a common, highly contagious bacterial skin infection (Options 3 and 5). Impetigo vesicles rupture and form erosions, and the fluid creates a honey-colored crust. Common sites include the mouth and hands. The nurse should be referred to occupational health and must cover the site while working. (Option 1) The medical-surgical nurse has the training to care for a client with immunosuppression and a broken leg. If chemotherapy needs to be administered during the hospitalization, a chemotherapy certified nurse will administer the medication. (Option 2) The client is not radioactive or infectious, and the nurse will not be administering or handling the chemotherapeutic agents. Therefore, it is safe for the pregnant nurse to care for the client. (Option 4) The injectable influenza vaccination does not contain live influenza virus; therefore, the unlicensed assistive personnel is not infectious. The inactivated vaccine is safe and recommended for clients who are immunocompromised.

While delegating to the unlicensed assistive personnel (UAP), the registered nurse (RN) should utilize the 5 rights of delegation. The "right direction and communication" related to the task is one of those rights. Which statement best meets that standard? 1. "I need for you to take vital signs on all clients in rooms 1-10 this morning." 2. "Mr. Wu's blood pressure has been low. Please take his vital signs first and let me know if his systolic blood pressure is <100." 3. "Mrs. Jones fell out of bed during the night. Be sure you keep a close eye on her this shift. 4. "Would you please make sure Mr. Garcia in bed 8 ambulates several times?"

2. "Mr. Wu's blood pressure has been low. Please take his vital signs first and let me know if his systolic blood pressure is <100." In the Joint Statement on Delegation (2007), the American Nurses Association and the National Council of State Boards of Nursing outline the 5 Rights of Delegation as seen in the table above. The RN needs to direct the UAP's actions and communicate clearly about the assigned tasks including any specific information necessary for completion (eg, methods for collection, time frame, when to report back to the RN). Option 2 gives the UAP directions with prioritization and specific instructions for reporting back findings. (Option 1) The time frame in this option should be more specific. In addition, there is no communication about what the RN expects as follow-up. (Option 3) The instruction to "keep a close eye" on the client leaves the UAP too much room for interpretation. The expectation from the RN is not clear and the UAP needs more direction. (Option 4) The instructions are too broad and don't give a specific time frame. This delegation also needs to communicate the method needed to accomplish the task.

The charge nurse in the emergency department assigns a client to a new nurse who has been off orientation for a week. Which client assignment is most appropriate? 1. 3-year-old with a temperature of 102.4 F (39.1 C) who had a seizure at home 30 minutes ago and is very irritable 2. 8-year-old with a closed fracture of the clavicle following a fall who is talkative and rates pain as a "2" on the 0-10 FACES pain scale 3. 32-year-old with asthma who has an upper respiratory tract infection and a peak expiratory flow rate that is 45% of personal best 4. 72-year-old prescribed antibiotics 3 days ago to treat acute sinusitis who reports shortness of breath and has a rash

2. 8-year-old with a closed fracture of the clavicle following a fall who is talkative and rates pain as a "2" on the 0-10 FACES pain scale A fractured clavicle (collarbone) is not uncommon in children age <10 years and is usually treated conservatively. A new nurse should be competent in performing the basic skills needed to care for a client with a musculoskeletal injury (eg, pain and neurovascular assessments, analgesia administration, sling application). The 8-year-old client, who has minimal pain as indicated by the score of 2 on the FACES pain assessment tool, is the most stable. As a result, this is the most appropriate assignment for the new nurse. (Option 1) A seizure can be associated with a fever-related illness (febrile seizure). This client who is very irritable and has fever may have an underlying serious infection such as meningitis and should undergo diagnostic testing (eg, blood cultures, imaging, lumbar puncture). Therefore, this is not an appropriate assignment. (Option 3) A peak flow meter measures airflow out of the lungs. The client who has a severely reduced peak expiratory flow rate (<50% of personal best) needs emergency intervention and is not an appropriate assignment. (Option 4) The client with dyspnea and a maculopapular drug rash is most likely experiencing an antibiotic-related allergic reaction, which can range from mild to life-threatening anaphylaxis. This client is not an appropriate assignment. Educational objective:A new nurse should be competent in performing the basic skills needed to care for a client with a musculoskeletal injury (eg, pain and neurovascular assessments).

The nursing team consists of a registered nurse (RN), licensed practical nurse (LPN), and 2 unlicensed assistive personnel (UAP). The nurse considers the assignment appropriate if the LPN is assigned to care for which pediatric client? 1. A 1-day-old with tracheoesophageal fistula scheduled for surgical repair today 2. A 6-month-old who had diaphragmatic hernia repair 5 days ago 3. A 12-year-old newly admitted with productive cough and white blood cell count of 15,000/mm3 4. A 16-year-old admitted for uncontrolled diabetes experiencing Kussmaul breathing

2. A 6-month-old who had diaphragmatic hernia repair 5 days ago The LPN should be assigned stable clients with expected outcomes. A 5-day post-diaphragmatic hernia client is stable at this time. The LPN cannot perform initial teaching, assessments, or evaluate a client condition (Option 2). (Option 1) This client is scheduled for surgery today and will require education and evaluation. (Option 3) This client is newly admitted to the unit and will need to be assessed by an RN. (Option 4) This client is not stable. The client is exhibiting signs of diabetic ketoacidosis and will require care provided by an RN.

Which client with an endocrine problem is most appropriate for the charge nurse to delegate to the licensed practical nurse (LPN)? 1. A client experiencing Addisonian crisis with a prescription for hydrocortisone IV 2. A client with Cushing syndrome who needs intermittent urinary catheterization 3. A client with diabetic ketoacidosis on insulin intravenous (IV) infusion 4. A client with thyrotoxicosis and new-onset atrial fibrillation

2. A client with Cushing syndrome who needs intermittent urinary catheterization Registered nurses (RNs) are able to delegate tasks to LPNs. The nurse delegating a task remains legally responsible for the client's total care during the shift, and may be held liable for delegating inappropriately. Routine procedures such as urinary catheterization fall well within the LPN scope of practice, the other clients are in crisis, requiring acute care. (Options 1, 3) LPNs are trained in many nursing skills; these include but are not limited to nasotracheal suctioning, Foley catheter and nasogastric tube insertion, dressing changes, and subcutaneous, intramuscular, and oral medication administration. However, IV medication administration is typically reserved for the RN. (Option 4) Frequent assessment of unstable clients or clients with changes in condition is an exclusive RN task. Other key components of RN practice that should not be delegated or assigned include planning, implementation of complex care, evaluation, and teaching.

The registered nurse is caring for multiple clients on a medical-surgical unit and has finished the morning assessment. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel? 1. Apply a collagenase dressing to a client's pressure ulcer for wound debridement 2. Assist a client 1 day postoperative hip fracture repair to the bathroom. 3. Feed a client through a gastrostomy tube after elevating the head of the bed 4. Offer orange juice to a client if the blood glucose level is <70 mg/dL (<3.9 mmol/L).

2. Assist a client 1 day postoperative hip fracture repair to the bathroom. Delegation is the process of transferring responsibility of performing a task while maintaining the ultimate responsibility for the action and its outcome. The registered nurse (RN) should take into account the five rights of delegation (right task, right person, right circumstances, right communication/direction, and right supervision/evaluation) and the scope of practice when deciding which tasks to delegate. The unlicensed assistive personnel (UAP) can assist clients out of bed or to the bathroom, assist with activities of daily living, and position clients. The RN is responsible for assessing the client and adhering to the nursing process. (Option 1) Debridement of a wound involves removing debris or dead tissue to convert contaminated wounds into clean wounds so that normal healing can take place. Dressing (eg, collagenase) changes for debridement require sterile technique; UAP can change dressings only for chronic wounds using clean technique. (Option 3) The UAP can elevate the head of the bed when a client receives enteral nutrition to prevent aspiration. However, feeding through a gastrostomy tube cannot be delegated to the UAP as it requires assessment of tube placement and aspiration of gastric residual volume. (Option 4) Offering orange juice is an intervention for treating hypoglycemia that is outside the UAP's scope of practice. The UAP should report the blood glucose level to the RN so that the RN can first reassess the client for accompanying symptoms of hypoglycemia; these would require RN assessment and interpretation before intervention.

The registered nurse (RN) and licensed practical nurse (LPN) are caring for a client with an established colostomy. Which nursing actions may the RN delegate to the LPN? Select all that apply. 1. Assess perfusion of the stoma tissue 2. Assist the client in changing the ostomy pouch 3. Auscultate the client's bowel sounds 4. Develop plan of care to prevent skin breakdown 5. Monitor the color of ostomy drainage

2. Assist the client in changing the ostomy pouch 3. Auscultate the client's bowel sounds 5. Monitor the color of ostomy drainage Tasks requiring initial assessment, initial or discharge education, care planning, or care of an unstable client require the clinical judgment of the registered nurse (RN) and may not be delegated. The RN may delegate care of stable clients with established ostomies to the licensed practical nurse (LPN). The following actions related to ostomy care are generally within the LPN scope of practice: Provide ostomy care and observe for skin breakdown (Option 2) Perform specific assessments (eg, bowel sounds, stoma color) (Option 3) Monitor drainage characteristics (eg, color, amount) (Option 5) Reinforce education Irrigate an established ostomy Document observations and interventions (Option 1) The RN may delegate specific assessments to the LPN. The LPN focuses on data collection and determining normal versus abnormal findings. For example, the LPN may determine that a client's colostomy stoma is an abnormal color whereas the RN synthesizes assessment findings (eg, color, temperature, capillary refill) to determine the quality of tissue perfusion. (Option 4) Developing the plan of care is the responsibility of the RN and cannot be delegated.

The nurse is caring for a hospitalized client with a diagnosis of thyrotoxicosis. Which of the following actions can be delegated to unlicensed assistive personnel? Select all that apply. 1. Administer artificial tears if the client reports eye dryness 2. Assist the client to bathe and change the bed linens to maintain client comfort 3. Lower the room temperature and provide cool cloths on request 4. Reinforce to the client that fever is expected with thyrotoxicosis 5. Return a call to the client's family telling them the client's condition is unchanged

2. Assist the client to bathe and change the bed linens to maintain client comfort 3. Lower the room temperature and provide cool cloths on request Thyrotoxicosis (thyroid storm), a complication of hyperthyroidism that occurs when excessive amounts of thyroid hormone are released into the circulation, requires monitoring (eg, telemetry) and supportive care for symptoms (eg, fever, tachycardia, hypertension, gastrointestinal distress). Clients with thyrotoxicosis may be very diaphoretic. Unlicensed assistive personnel (UAP) can promote the client's comfort by providing showers or bed baths and frequent linen changes (Option 2). UAP can also help maintain comfort by ensuring that the client has ice water, lowering the room temperature, and providing cool cloths (Option 3). (Option 1) Medication administration (eg, administering eye drops) falls under the scope of practice of a registered nurse (RN) or practical nurse (PN) and should never be delegated to UAP. (Option 4) Client teaching (eg, reinforcing expected symptoms) falls only under a nurse's scope of practice and cannot be delegated to UAP. The RN performs initial teaching, and both the RN and the PN reinforce teaching as needed. (Option 5) Although placing a phone call can be delegated, providing family with updates about the client's condition may require teaching and psychosocial support; therefore, it is not an appropriate task for UAP. Educational objective:Assisting clients with routine care and activities of daily living, such as bathing, linen changes, and adjustment of room temperature, is a therapeutic action that can be delegated to unlicensed assistive personnel (UAP). Key components of the nursing process (eg, assessment, diagnosis) and tasks requiring nursing judgment (eg, medication administration, teaching) cannot be delegated to UAP.

Which actions are appropriate for the registered nurse to delegate to an experienced licensed practical nurse? Select all that apply. 1. Administer heparin continuous infusion to a client with a venous thromboembolism 2. Auscultate bowel sounds 2 days after repair of an inguinal hernia 3. Discuss concerns about last shift's care with an irate family member 4. Monitor flow rate and drainage in a client receiving bladder irrigation 5. Teach Kegel exercises after a client has a catheter

2. Auscultate bowel sounds 2 days after repair of an inguinal hernia 4. Monitor flow rate and drainage in a client receiving bladder irrigation Licensed practical nurses (LPNs) can execute higher-level skills under the direction of a registered nurse (RN). These include administering routine medications for expected needs and performing focused assessments such as breath sounds, bowel sounds, and neurovascular checks (eg, pulse, capillary refill, numbness) (Option 2). LPNs can also monitor findings such as flow rate and drainage in a client receiving continuous bladder irrigation (Option 4). Initial admission or postoperative assessments must be completed by the RN. (Option 1) Continuous IV drug infusions are managed by the RN. This is especially true with drug categories such as anticoagulants, which will require titration depending on client response. (Option 3) In this situation, the LPN is not explaining the LPN's own care to the family, but rather that provided by others on a different shift. Issues related to unit management should be handled by the charge RN. (Option 5) Initial teaching should be performed by the RN. The LPN can reinforce the RN's initial teaching.

The nurse practicing on a medical surgical unit cares for a client with type I diabetes mellitus. Which action should the nurse delegate to experienced unlicensed assistive personnel (UAP)? 1. Assess the client for signs and symptoms of hypoglycemia 2. Check the blood glucose before meals and report it to the primary nurse. 3. Teach the client to cut toenails straight across and file with rounded curves of the toes. 4. Update the care plan to include client's preference for nighttime diabetic snack.

2. Check the blood glucose before meals and report it to the primary nurse. Key components of the nursing process, such as assessment, diagnosis, planning, and evaluation, fall under the scope of practice of the registered nurse (RN) and should not be delegated. In addition, teaching falls within the scope of practice of the RN and should not be delegated to UAP. Some skills, such as obtaining a blood glucose level, can be delegated to UAP as long they have received documented training and have demonstrated competency. Remember that the 5 rights of delegation are: Right task Right circumstance Right person Right direction and communication Right supervision and evaluation (Option 1) Assessment falls within the scope of practice of the RN and should not be delegated. When UAP report an observation or communicate a client symptom to the nurse, it is the nurse's responsibility to assess the client. (Option 3) Teaching falls within the scope of practice for the registered nurse. Other members of the health care team, such as licensed vocational nurses or licensed practical nurses, may reinforce teaching as outlined in the care plan after it has been initiated by the RN. (Option 4) Planning includes initiating and updating the client's plan of care and falls within the scope of practice of the RN and should not be delegated to UAP.

A float nurse from labor and delivery is assigned to the cardiac care unit. Which client is most appropriate for the charge nurse to assign to the float nurse? 1. Client 3 days following a myocardial infarction who is on 6 L of oxygen and reports nausea 2. Client admitted for hypertensive crisis with blood pressure of 154/92 mm Hg on amlodipine PO 3. Client with a demand pacemaker set at 70/min who has a ventricular rate of 65/min 4. Client with angina at rest who has normal troponin levels and normal sinus rhythm on ECG

2. Client admitted for hypertensive crisis with blood pressure of 154/92 mm Hg on amlodipine PO A hypertensive crisis is an elevation in blood pressure (BP) >180 mm Hg systolic and/or >120 mm Hg diastolic with evidence of organ damage (eg, kidney damage, retinopathy). The goal of treatment is to slowly lower BP using IV antihypertensive medications (eg, vasodilators) to limit end-organ damage. Once the client's condition is stabilized, oral antihypertensives are prescribed and IV medications are titrated off. Float nurse assignments should be made on the basis of what is within the knowledge and skill of the generalist nurse. The float nurse can safely care for the client whose BP is controlled by oral medication, and has the knowledge and skill to assess vital signs (Option 2). (Option 1) The client with a history of myocardial infarction showing signs of reinfarction (eg, nausea, increased oxygen demands) may be unstable and should not be assigned to the float nurse. (Option 3) A ventricular rate of 65/min observed in a client with a demand pacemaker rate of 70/min indicates a malfunction in sensing or capturing the client's heart rate. An experienced cardiac nurse should care for this client. (Option 4) Unstable angina (angina at rest) is a medical emergency that requires specialist-level monitoring and intervention.

The registered nurse (RN) prepares to give out client care assignments. Which client is appropriate for the RN to assign to the licensed practical nurse (LPN)? 1. Client admitted 3 hours ago with suspected acute pancreatitis 2. Client who had a total right hip replacement 2 days ago. 3. Client who had a total thyroidectomy 2 hours ago. 4. Client with alcohol withdrawal syndrome.

2. Client who had a total right hip replacement 2 days ago. The LPN should be assigned to clients who are medically stable and have expected outcomes; these criteria apply to the client who had a total hip replacement 2 days ago. LPNs should not be assigned to clients who require complex care and clinical judgment and have potential negative outcomes. Teaching, assessment, clinical judgment, and evaluation of a client are the responsibility of the RN and should never be delegated to the LPN. (Option 1) Client care is complex for those with acute pancreatitis as they can develop several complications (eg, hypocalcemia, acute respiratory distress syndrome) and need aggressive supportive care (eg, pain management, IV fluids). (Option 3) Total thyroidectomy can be complicated by bleeding (throat compression) or hypocalcemia (if parathyroids were removed inadvertently). Care in these clients is complex. (Option 4) Alcohol withdrawal can develop into delirium tremens or seizures; both are serious conditions. Clients need frequent doses of benzodiazepines (eg, lorazepam, diazepam) and aggressive supportive care.

A client is admitted with a lower urinary tract infection from an obstructing ureteral stone. Which tasks can the registered nurse (RN) delegate to the experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Assisting the client in completing a health history form 2. Collecting a urine specimen for culture and sensitivity 3. Instructing the client to strain urine when voiding 4. Measuring and documenting urine output 5. Monitoring the color and characteristics of urine output

2. Collecting a urine specimen for culture and sensitivity 4. Measuring and documenting urine output. Measuring intake and output and obtaining a urine specimen for culture and sensitivity are both appropriate duties to delegate to the UAP. Objective measurements (eg, vital signs, intake and output) do not require assessment skills and are therefore appropriate for delegation (Option 4). Nursing actions that require assessment, teaching, evaluation, or clinical judgment must be performed by the RN. Collecting a urine specimen is a routine task with a predictable outcome and is therefore appropriate for delegation to the experienced UAP under the instruction and supervision of the RN (Option 2). The RN should always observe the five rights of delegation by verifying that the UAP have the skills and experience necessary to collect a urine specimen without contamination. If this client had a Foley catheter, specimen collection would be inappropriate for delegation to the UAP. Collecting a specimen from a Foley catheter is considered a sterile procedure as it involves accessing a sterile collection port and risks introducing bacteria into the closed drainage system if done improperly. However, when provided with the appropriate instructions, the UAP and even clients themselves may collect a clean-catch or midstream urine specimen. (Option 1) Conducting a review of the client's complete past medical history is an important responsibility of the RN during the admission assessment. This requires skills and understanding beyond the level of the UAP. (Option 3) Client education about the procedure and rationale for straining urine is the responsibility of the RN. After the RN assesses the knowledge and competency level of the UAP, the UAP can gather supplies, remind the client to strain the urine, and report any abnormal findin

The nurse is assisting the health care provider with a lumbar puncture in the client's room. The unit secretary calls over the room intercom and tells the nurse that the laboratory is on the phone with a critical value report for one of the nurse's other clients. What action should the nurse take? 1. Ask the unit secretary to write down a message from the laboratory personnel 2. Instruct the unit secretary to have the charge nurse receive the report 3. Leave the room to talk to the laboratory on the phone and then return immediately 4. Tell the unit secretary to have laboratory personnel send a written result

2. Instruct the unit secretary to have the charge nurse receive the report A critical value is a result that is significantly abnormal and requires the nurse to contact a provider immediately to initiate appropriate interventions. An example is a potassium level of 7 mEq/L (7 mmol/L). The nurse should delegate the task to the charge nurse so appropriate interventions can be initiated while the nurse finishes the sterile procedure (Option 2). This is the option with the least client risk. Timely reporting of critical results is part of the International Patient Safety Goals. (Option 1) The unit secretary does not have the background, training, experience, and education to understand the implications of the critical value or know the next step. A registered nurse or other licensed practitioner must take the report. (Option 3) The nurse cannot "abandon" the client in the middle of a sterile procedure to take the report. (Option 4) The typical policy calls for the laboratory to verbally communicate critical results and document which nurse took the report. A written report may never be received or the nurse may forget to look for it. The best response is to have another nurse take the report.

The nurse is preparing to administer a unit of packed red blood cells to a client whose hemoglobin is 7 g/dL (70 g/L). What tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply. 1. Assist with checking identification of the client and the blood product 2. Measure vital signs at the end of the transfusion 3. Measure vital signs prior to starting the transfusion 4. Measure vital signs within the first 10 minutes of starting the transfusion 5. Pick up blood from the blood bank

2. Measure vital signs at the end of the transfusion 3. Measure vital signs prior to starting the transfusion 5. Pick up blood from the blood bank The registered nurse (RN) is responsible for most of the care rendered to a client during a blood transfusion as this is considered a high-acuity procedure requiring a high level of nursing assessment and judgment. Based on the individual state or provincial practice act and institutional policy, the RN may have assistance from a licensed practical nurse with checking blood products, verifying client identification, and monitoring the blood transfusion rate. Unlicensed assistive personnel (UAP) can obtain the blood product from the blood bank and courier it to the floor where the RN will verify the blood product with another nurse (Option 5). UAP can also take vital signs before the transfusion begins and any time after the first 15 minutes of infusion (Options 2 and 3). (Option 1) Only nurses are able to verify blood product and client identification for blood transfusion procedures. (Option 4) It is the responsibility of the RN to stay with the client during the first 15 minutes of the transfusion, monitor client response, and measure vital signs. A transfusion reaction is most likely to occur during this time. However, the RN may delegate measurement of vital signs after the first 15 minutes.

All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which tasks are appropriate for the registered nurse (RN) to delegate to the UAP to promote client safety? Select all that apply. 1. Orient the client to the bedside unit and explain the call bell system on admission 2. Place the bedside commode as close to the bed as possible 3. Remind the client to change position slowly 4. Report observations of changes in client's condition immediately 5. Report whether client is using correct gait and balance while ambulating with walker

2. Place the bedside commode as close to the bed as possible 3. Remind the client to change position slowly 4. Report observations of changes in client's condition immediately The RN can safely delegate the following tasks to the UAP to promote client safety during toileting and ambulating: Place the bedside commode, assistive devices (eg, canes, walkers), and personal belongings (eg, eyeglasses, hearing aids, cell phones) as close to the client as possible Remind the client of the importance of changing position slowly to minimize orthostatic hypotension Report observations of changes in the client's condition (eg, level of consciousness, vital signs, pain level) immediately Keep the bed in the lowest position (locked) as it reduces the distance to the floor in the event of a fall Provide nonskid footwear for the client before ambulating Keep the environment dry and free of clutter and obstacles (eg, intravenous infusion device tubing and poles, electronic device wires and cords) (Option 1) The risk of falling is highest on the night of admission. Clients wake in the middle of the night, attempt to get up unassisted in unfamiliar surroundings, and fall. Client orientation and teaching are the responsibilities of the RN and are not appropriate to delegate to the UAP. (Option 5) Alterations in gait, balance, and range of motion places the client at a higher risk for falling. Evaluating the client for gait and balance deficits requires assessment and is a function of the registered nurse. The UAP may assist the client in ambulating with assistive devices, but evaluating and educating are not delegated. Educational objective:Most client falls are unobserved and occur in the client's room or bathroom. Assessment, client orientation, and teaching are the responsibilities of the RN and are not appropriate to delegate to the

A nurse is preparing to perform postmortem care on a client who recently died from metastatic cancer. No family members were present at the time of death. What interventions can be delegated to experienced unlicensed assistive personnel? Select all that apply. 1. Notifying the family of the client's death 2. Placing dentures in the client's mouth 3. Positioning a pillow beneath the client's head 4. Transporting the client to the morgue 5. Washing the client's body

2. Placing dentures in the client's mouth 3. Positioning a pillow beneath the client's head 4. Transporting the client to the morgue 5. Washing the client's body. It is appropriate to delegate postmortem care to unlicensed assistive personnel (UAP) if they have been trained and have sufficient experience in the procedures (5 rights of delegation). Postmortem care involves the following series of steps: Wash and straighten the body (Option 5), change the linens, and place a pad under the perineum to absorb stool and urine from relaxed sphincters. Place a pillow under the head (Option 3) to prevent blood from pooling and discoloring the face. Place dentures in the client's mouth before rigor mortis sets in (Option 2) and close the mouth. Gently close the eyes. Remove tubes, lines, and dressings per institutional policy unless an autopsy or organ donation is to be performed. After the family leaves, take the client to the morgue or notify the funeral home to arrange transportation (Option 4). (Option 1) Family members are usually notified by the health care provider. Most likely they will ask questions that the UAP would be unable to answer. This task would not be appropriate for delegation.

The clinical coordinator registered nurse (RN) on a surgical unit makes assignments for the staff of RN, licensed practical nurse, and graduate nurse. Which assignment is most appropriate for a new graduate nurse? 1. A 36-year-old client with postoperative venous thromboembolism who is to be started on the institution's intravenous heparin therapy protocol this morning 2. A 56-year-old client with newly diagnosed cancer, scheduled for a total laryngectomy this morning, who is now refusing surgery 3. A 68-year-old client with multiple sclerosis, 2 days postoperative open cholecystectomy with recurrent mucous plugs, who is scheduled for a bronchoscopy this morning 4. An 80-year-old client, 3 days postoperative colectomy with peritonitis, who was mentally alert before and develops new-onset confusion this morning

3. A 68-year-old client with multiple sclerosis, 2 days postoperative open cholecystectomy with recurrent mucous plugs, who is scheduled for a bronchoscopy this morning To prepare a client for a bronchoscopy, the nurse must be able to perform basic assessment skills, such as assessing vital signs, lung sounds, ability to swallow, and gag reflex; maintain nothing-by-mouth status; prepare a checklist before the procedure; and monitor for respiratory difficulty after the procedure. Because these are skills a graduate nurse possesses, this is an appropriate assignment.(Option 1) Initiating a heparin infusion according to institution protocol involves collecting baseline serum specimens (eg, partial thromboplastin time [aPTT], International Normalized Ratio [INR], prothrombin time, platelets, hemoglobin, hematocrit), calculating weight-based dosages, (eg, bolus dose, infusion rate in units/hr), and calculating intravenous infusion pump hourly rate. Serum aPTT and INR levels are monitored every 6 hours or according to protocol. Frequent changes in rate or dose based on these levels may be necessary to maintain a therapeutic level of heparin. For these reasons, this is not an appropriate assignment for a new graduate nurse.(Option 2) A client with newly diagnosed cancer who is refusing radical surgery that will result in the loss of speech and inability to communicate normally is demonstrating fear and anxiety. This client needs preoperative teaching about the surgical procedure, what to expect immediately after surgery, methods for speech restoration, and general preoperative teaching (eg, deep breathing, suctioning, pain management). Emotional support, education, and advanced therapeutic communication skills are necessary to help allay fear and anxiety. For these reasons, this is not an appropriate assignment for a new gra

A pediatric nurse is floated to an adult medical surgical unit. Which client assignment would be most appropriate for the pediatric nurse? 1. Client with alcohol withdrawal who needs IV lorazepam every 2 hours 2. Client with emphysema and an oxygen saturation of 89% on room air 3. Client with sickle cell crisis requiring IV morphine every 2 hours 4. Client with type 2 diabetes mellitus who needs discharge teaching

3. Client with sickle cell crisis requiring IV morphine every 2 hours. The most appropriate assignment for the pediatric nurse is the client with sickle cell anemia requiring IV morphine every 2 hours. Sickle cell anemia is a common disorder in children and the pediatric nurse would be familiar with the assessment, plan of care, and treatment of clients with sickle cell crisis. (Option 1) Alcohol withdrawal is predominantly a disease of adults. A pediatric nurse would have little experience managing clients with delirium tremens. (Option 2) Emphysema is a chronic obstructive lung disorder not commonly seen in pediatric clients. It occurs later in life as a result of long-term smoking. (Option 4) Type 2 diabetes mellitus is increasing in incidence in the pediatric population. However, discharge teaching would be performed better by a nurse from the adult medical surgical unit who has more experience with the disease and discharge paperwork. Educational objective:A pediatric nurse who is floated to an adult medical surgical unit should be assigned clients with diagnoses common to the pediatric client population. Some examples include sickle cell anemia, diabetic ketoacidosis, pneumonia, and acute appendicitis.

The registered nurse, licensed practical nurse (LPN), and unlicensed assistive personnel are assigned a client who is being transferred from the post-anesthesia care unit (PACU). Which tasks are the most appropriate to delegate to the LPN? Select all that apply. 1. Assess the client on admission 2. Measure vital signs and pulse oximetry 3. Monitor pain level and administer pain medications 4. Receive verbal report from the PACU nurse 5. Reposition client every 2 hours 6. Titrate oxygen based on unit protocols

3. Monitor pain level and administer pain medications 6. Titrate oxygen based on unit protocols The registered nurse (RN) should consider the 5 rights of delegation prior to delegating a task. Tasks such as monitoring pain, administering medications, and titrating oxygen may be delegated by the RN to the licensed practical nurse (LPN) (Options 1 and 4) The RN receives report from the post-anesthesia care unit nurse, performs initial assessments, and performs other tasks requiring critical judgment (eg, initial teaching, care planning). (Options 2 and 5) Client positioning and measurement of vital signs and pulse oximetry may be delegated to unlicensed assistive personnel (UAP). Although LPNs can carry out these tasks, their time is better spent performing more complex client care (eg, medication administration) if UAP is available.

The registered nurse (RN) is caring for a client with tuberculosis who is on airborne isolation precautions. The RN can delegate which tasks to the experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Alert the x-ray department about maintaining airborne isolation precautions 2. Explain to the client why the client must wear a mask during transport to another department 3. Post signs for airborne isolation precautions on the client's door and stock necessary equipment 4. Remind visitors to wear a respirator mask and keep the door closed while in the client's room 5. Talk with the family about the reasons for airborne isolation precautions in the client

3. Post signs for airborne isolation precautions on the client's door and stock necessary equipment 4. Remind visitors to wear a respirator mask and keep the door closed while in the client's room The RN can delegate the following tasks to the experienced UAP: Post signs for airborne isolation precautions on the client's door and stock necessary equipment: The UAP has the knowledge and skill to implement isolation precautions when caring for clients on contact, droplet, or airborne transmission-based precautions (Option 3). Remind visitors to wear a respirator mask and keep the door closed while in the client's room: The UAP can reinforce the procedures and principles of infection control regarding airborne isolation precautions (eg, respirator masks, negative airflow room). However, the nurse should provide the initial instructions and is responsible for visitor compliance (Option 4). (Option 1) The RN is responsible for calling the x-ray or other departments to communicate pertinent information about the client, including the need to maintain airborne isolation precautions before and while transporting the client for diagnostic tests. (Option 2) The RN is responsible for explaining to the client that wearing a mask during transport to another department prevents transmission of airborne microorganisms from the client to others. This is client teaching and must be done by the RN. The UAP can implement the task of applying the mask before transport. (Option 5) The RN is responsible for talking with the family about the reasons the client is on airborne isolation precautions and teaching them about preventing the spread of the disease by wearing protective equipment upon entering the client's room. Educational objective:Experienced UAP can post signs on the client's door that display airborne isolation precautions, stoc

The charge nurse on a medical unit makes assignments for the nursing team composed of a registered nurse (RN), 2 licensed practical nurses (LPNs), and a student nurse (SN). Which assignment is the most appropriate? 1. LPN assigned to a client with a gastrointestinal bleed and hypotension who is receiving blood and requires vital sign monitoring every hour 2. LPN assigned to a newly admitted client with a bowel obstruction who is experiencing severe abdominal pain 3. RN assigned to a client with a change in mental status who is being transferred to the intensive care unit 4. SN assigned to a client with multiple sclerosis and dysphagia who requires multiple oral and IV medications

3. RN assigned to a client with a change in mental status who is being transferred to the intensive care unit A client experiencing changes in mental status severe enough to require transfer to the intensive care unit (ICU) is considered critically ill and is the most appropriate assignment for the RN. This client is unstable and requires the RN's advanced skills to perform ongoing neurological assessments (eg, respiratory pattern, level of consciousness, mental status, motor and sensory activity) and vital sign checks, to document findings, and to report the client's condition to the ICU nurse until the transfer can be completed. (Option 1) This client is unstable and requires continuous assessment in a complex situation. Some states allow only RNs to administer blood transfusions. This assignment is not appropriate for an LPN. (Option 2) Accurate assessment of pain and bowel sounds (eg, presence, absence, pitch) is critical in a newly admitted client with a bowel obstruction and should be performed by the experienced RN; this assignment is not appropriate for an LPN. (Option 4) This client is at increased risk for aspiration; much of the RN's time will be spent observing and supervising the administration of oral and IV medications. This assignment is not appropriate for an SN. Educational objective:The more experienced RN is assigned to the client with more complex needs that require a more advanced level of nursing skill and judgment. LPNs can perform noninvasive interventions and certain invasive tasks for more stable clients.

The charge nurse on a medical-surgical step-down unit is responsible for making assignments. Which client is most appropriate to assign to a new graduate nurse who is still in orientation? 1. 65-year-old client 1 day postoperative left femoral-popliteal bypass graft surgery with a diminished pedal pulse 2. 66-year-old client admitted for hypertensive crisis 2 days ago; blood pressure currently 180/102 mm Hg; reports headache and blurred vision 3. 75-year-old client with an ischemic stroke transferred from the intensive care unit 1 hour ago; unresponsive with right-sided paralysis 4. 78-year-old client with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage

4. 78-year-old client with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage Rationale: The new nurse has the basic skills to provide insulin coverage if necessary, perform wound care (eg, assessment, sterile dressing changes, documentation), and provide diabetic teaching for this client. (Option 1) A more experienced nurse should care for this client as frequent assessments are needed to determine artery patency and changes in circulatory status distal to the graft, especially in the presence of a diminished pedal pulse. (Option 2) A more experienced nurse should care for this client due to frequent assessments and neurologic checks to determine the possible development of target organ disease (eg, brain, heart, lungs, kidneys), especially in the presence of headache and visual disturbances. (Option 3) A more experienced nurse should care for this client due to airway management, aspiration precautions, blood pressure control, and frequent assessments to determine changes in neurologic status. Educational objective:The registered nurse makes assignments according to staff members' experience, knowledge, and skill level. The more experienced nurse is assigned to clients who are less stable and require more in-depth analysis of assessment data to implement and plan care. The less experienced graduate nurse is assigned to more stable clients who require basic nursing care.

The charge registered nurse (RN) on a medical-surgical unit is responsible for making assignments. Which assignment made by the RN is most appropriate? 1. A licensed practical nurse (LPN) assigned to a client receiving blood transfusions 2. A student nurse assigned to a client who requires frequent intravenous pain medication 3. An LPN assigned to a client 2 days postoperative appendectomy scheduled to be discharged today 4. An RN assigned to a client 1 day postoperative repair of a compound fracture

4. An RN assigned to a client 1 day postoperative repair of a compound fracture An RN is appropriately assigned to the client who is most unstable. Following this client's orthopedic surgery, the nurse must perform frequent neurovascular, pain, drain, wound, and respiratory assessments; assess for potential risk factors (eg, pulmonary embolus); and provide emotional support as well. Good critical thinking skills are needed to develop, implement, and evaluate an appropriate plan of care for this client. (Option 1) Administration of blood is not within the scope of the LPN's practice. (Option 2) A student nurse may not be able to administer medications independently and/or would require close supervision by either nursing faculty or an RN preceptor. The student nurse may not be able to provide adequate pain relief in a timely manner. The nurse who assesses the pain should administer the medication and evaluate the response. (Option 3) A postoperative client requires thorough education and evaluation prior to discharge. This level of client education should be performed by an RN; an LPN may reinforce prior teaching completed by an RN but is not able to provide initial teaching or evaluate learning outcomes.

The nurse is making assignments for the next shift. Which client should the nurse assign to the new nurse coming out of orientation? 1. Client diagnosed with chronic anemia receiving iron via IV route. 2. Client newly admitted for uncontrolled diabetes mellitus type 2 with blood glucose >600 mg/dL (33.3 mmol/L). 3. Client undergoing ultrafiltration for congestive heart failure. 4. Client with a prescription for routine hemodialysis who has chronic renal failure.

4. Client with a prescription for routine hemodialysis who has chronic renal failure. The nurse is looking for the most stable client to assign to the new nurse. The client who is scheduled for hemodialysis has a chronic disorder and receives this therapy on a regular basis. There is no indication that this client might be unstable. (Option 1) There is a high incidence of IV iron causing hypersensitivity reactions, including anaphylaxis. Therefore, a test dose needs to be given first. This client should be assigned to a more experienced nurse. (Option 2) The client with hyperglycemia is at high risk for diabetic ketoacidosis or hyperglycemic hyperosmolar nonketotic coma. Both are associated with acute and chronic complications and require careful assessment and prompt nursing intervention. This client should also be assigned to a more experienced nurse. (Option 3) Ultrafiltration (removal of excess fluid) is a complex task that requires extra training to perform. It is performed for clients who are not responding to IV diuretics. In addition, clients receiving ultrafiltration are more likely to be hemodynamically unstable due to their advanced heart failure; therefore, it is better for these clients to receive care from an experienced nurse.

Which client is most appropriate for the charge nurse in the postpartum unit to assign to the float nurse from the intensive care unit? 1. Client experiencing fever and pain with mastitis 2. Client preparing for discharge after cesarean birth 3. Client showing disinterest in caring for the newborn 4. Client with hysterectomy after postpartum hemorrhage

4. Client with hysterectomy after postpartum hemorrhage Explanation. Float nurses should be assigned to clients who most reflect the client population with which they are familiar. Safety is a priority when making client assignments. Explanation: The client with blood loss leading to a hysterectomy would require close observation of hemodynamic status. Signs could be subtle, and the nurse floating from the intensive care unit would have the assessment skills needed to recognize any changes. (Option 1) Mastitis is a very painful infection. A postpartum nurse would be most familiar with the comfort measures associated with mastitis. (Option 2) A client preparing for discharge after cesarean birth would require an experienced postpartum nurse as discharge instructions would involve teaching related to both the newborn and the client. (Option 3) Psychosocial adjustment after giving birth can be complex. An experienced postpartum nurse would be trained to assess for signs of adjustment issues.

The labor and delivery (L&D) nurse is floated to a medical-surgical floor for a shift. Which client is most appropriate for the charge nurse to assign to the L&D nurse? 1. Client with an occluded arteriovenous fistula receiving IV heparin infusion 2. Client with cirrhosis and ascites who requires bedside paracentesis 3. Client with diabetes who is one day postoperative below-the-knee amputation 4. Client with pyelonephritis who is febrile and receiving IV antibiotics

4. Client with pyelonephritis who is febrile and receiving IV antibiotics Nurses must sometimes "float" to a nursing unit outside of their normal area of practice based on staffing needs. A nurse who floats to an unfamiliar practice area should be assigned clients who do not require specialized knowledge and can be safely managed with similar skills as with their usual client population. It is the responsibility of the floated nurse to inform the supervisor of any lack of experience with the client population and to request orientation to the unit. Labor and delivery (L&D) nurses possess focused knowledge and training to care for the obstetric population but are able to generalize many skills to other client populations. L&D nurses frequently care for pregnant women with urinary tract infections and would be familiar with the management of a client with pyelonephritis. The administration of IV antibiotics is a general nursing skill with which all nurses should be familiar (Option 4). (Option 1) The L&D nurse is likely unfamiliar with IV heparin administration, which requires close monitoring and specific knowledge of infusion titration. (Option 2) The L&D nurse likely lacks the specific knowledge required to assist with bedside paracentesis and monitor for potential post-procedure complications. (Option 3) A client who undergoes an amputation has unique educational and care needs, with which the L&D nurse is likely unfamiliar.

The night charge nurse is making assignments for the next shift. Which client is most appropriate to assign to a nurse with less than a year of experience who is floated from the orthopedic unit to the medical unit? 1. Client newly admitted for an evolving ischemic stroke. 2. Client newly diagnosed with diabetes mellitus who needs insulin administration teaching. 3. Client with exacerbation of chronic obstructive pulmonary disease (COPD) with a new tracheostomy. 4. Client with sickle cell crisis who requires frequent intravenous (IV) opioid medication for pain

4. Client with sickle cell crisis who requires frequent intravenous (IV) opioid medication for pain. Sickle cell crisis is managed with IV hydration, frequent IV pain medication, and as-needed blood transfusion. Many orthopedic clients require medication with opioids to control pain, IV fluids, and blood transfusion (blood loss with surgery/trauma). The float nurse is familiar with the policies and procedures for pain assessment and administering opioid medications, which should be the same on non-specialty units within the same facility. (Option 1) The client newly admitted for an evolving ischemic stroke is best assigned to an experienced nurse who regularly works on the unit. The nurse will perform baseline and frequent follow-up neurologic assessments to determine if the client's condition is worsening. (Option 2) The client newly diagnosed with diabetes mellitus who needs insulin administration teaching is best assigned to a nurse who regularly works on the unit. The nurse would be familiar with the location of diabetic teaching materials, documentation procedure, and referral resources, and would be better able to evaluate the client's understanding and performance of insulin administration the next day. (Option 3) The client with exacerbation of COPD with a new tracheostomy is best assigned to an experienced nurse who regularly works on the unit. Care of a new tracheostomy requires the nurse to be familiar with assessment (eg, appearance, bleeding) and care (eg, suctioning).

When making assignments in the labor and delivery unit, the charge nurse should assign the most experienced newborn admit nurse to attend to the birth of which client? 1. Client with diet-controlled gestational diabetes 2. Client with mild preeclampsia and blood pressure averaging 140/90 mm Hg 3. Client with premature rupture of membranes 6 hours ago at 37 weeks gestation 4. Client with spontaneous rupture of membranes with greenish amniotic fluid

4. Client with spontaneous rupture of membranes with greenish amniotic fluid Green amniotic fluid indicates that the fetus has passed its first stool (meconium) in utero. Meconium-stained amniotic fluid places the newborn at risk for meconium aspiration syndrome, a type of aspiration pneumonia. A skilled neonatal resuscitation team should be present at the birth of any newborn with meconium-stained fluid for immediate evaluation and stabilization (Option 4). Previously, endotracheal (ET) suctioning was recommended for nonvigorous newborns (eg, depressed respirations, decreased muscle tone, heart rate <100/min) born with meconium-stained fluid; however, recent guidelines indicate that routine ET suctioning is no longer necessary. (Option 1) Neonates born to mothers with gestational diabetes are at risk for hypoglycemia after birth and should be monitored closely during the first 6 hours of life. The risk of newborn hypoglycemia is lower if the mother's diabetes is well-controlled and not insulin-dependent. (Option 2) Clients with severe preeclampsia may need magnesium sulfate therapy for seizure prevention. Maternal magnesium therapy can cause newborn respiratory depression at birth. However, this client's mild preeclampsia does not require magnesium therapy. (Option 3) Premature rupture of membranes (PROM) refers to the rupture of membranes prior to the onset of labor at term gestation (≥37wk 0d). PROM on its own does not harm the fetus. However, if labor does not begin after PROM, induction of labor may be necessary to decrease the risk for infection (eg, chorioamnionitis). Educational objective:Meconium-stained amniotic fluid places the newborn at risk for meconium aspiration syndrome. A skilled neonatal resuscitation team should be present at birth for immediate newborn evaluation and stabilization.

The unlicensed assistive personnel (UAP) notifies the charge nurse that the client told the UAP that the client is feeling short of breath. What should the charge nurse do first? 1. Activate a rapid response team 2. Ask the UAP to take vital signs and report back 3. Notify the client's assigned licensed practical nurse (LPN) to assess the client 4. Personally go and auscultate the client's lungs

4. Personally go and auscultate the client's lungs When a registered nurse (RN) receives a report of a client complaint that is potentially ominous from a staff member of lesser qualifications, the RN should personally assess the client. This is the primary nursing assessment that will be used to decide if an urgent need exists and a change in the nursing plan of care is needed. (Option 1) It is important to assess the client prior to acting (the nursing process) on initiating a rapid response team based on a report from a staff member with less knowledge and skills. The nurse may not find an acute client need during the assessment. (Option 2) The UAP could be asked to go with the RN and obtain vital signs as the RN is assessing the client, but the UAP should not be asked to independently obtain this assessment first. (Option 3) The RN should assess the client personally rather than assign the task to the LPN. LPNs are assigned clients who are basically stable. The RN should be involved when there is new-onset potential instability in a client's condition.

The unlicensed assistive personnel on the cardiac floor reports to the registered nurse that during the first vital sign measurement on the shift, a client's blood pressure measured 198/102 mm Hg on the automated blood pressure machine. What action should the nurse take first? 1. Have the unlicensed assistive personnel recheck the client's blood pressure 2. Immediately notify the health care provider 3. Obtain the client's PRN labetalol from the medication dispensing machine 4. Recheck the client's blood pressure with a manual cuff

4. Recheck the client's blood pressure with a manual cuff This client's abnormally high blood pressure increases the risk for complications such as stroke. The nurse should assess this client and recheck the blood pressure with a manual cuff to verify the accuracy of the previous measurement taken by the unlicensed assistive personnel (UAP). The nurse will need to assess the client further before making additional nursing judgments and taking action. (Option 1) The nurse should not instruct the UAP to perform additional blood pressure measurements as this client could have severe hypertension; delegation of such a task is inappropriate (does not fit the "right circumstances" for delegation). If the client's reading is not as high as previously thought after blood pressure measurement with a manual cuff, the nurse can then instruct the UAP to take subsequent measurements with a different automatic blood pressure machine. (Option 2) The nurse may need to notify the health care provider but only after the client has been assessed further by the nurse. (Option 3) The client's blood pressure must be verified for accuracy before administering a PRN antihypertensive. Educational objective:When the unlicensed assistive personnel (UAP) reports an abnormal vital sign to the nurse, the nurse should assess the client further. It is inappropriate delegation to have the UAP recheck the client.