Delegation Questions
A patient with a fractured fibula is receiving skeletal traction and has skeletal pins in place. What would the nurse instruct the unlicensed assistive personnel (UAP) to report immediately? 1. The patient wants to change position in bed. 2. There is a small amount of clear fluid at the pin sites. 3. The traction weights are resting on the floor. 4. The patient reports pain and muscle spasm.
3 When the weights are resting on the floor, they are not exerting pulling force to provide reduction and alignment or to prevent muscle spasm. The weights should always hang freely. Attending to the weights may reduce the patient's pain and spasm. With skeletal pins, a small amount of clear fluid drainage is expected. It is important to inspect the traction system after a patient changes position because position changes may alter the traction.
The nurse is instructing a senior nursing student on the techniques for palpation of the thyroid gland. What precaution would the nurse be sure to include when instructing the student about thyroid palpation? 1. Always stand to the side of the patient. 2. Instruct the patient not to swallow. 3. Palpate using one hand and then the other. 4. Always palpate the thyroid gland gently.
4 The thyroid gland should always be palpated gently because vigorous palpation can stimulate a thyroid storm in a patient who may have hyperthyroidism. The student nurse should stand either behind or in front of the patient and use both hands to palpate the thyroid. Having the patient swallow can help with locating the thyroid gland.
In the care of clients with pain and discomfort, which task is most appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Assisting the client with preparation of a sitz bath 2. Monitoring the client for signs of discomfort while ambulating 3. Coaching the client to deep breathe during painful procedures 4. Evaluating relief after applying a cold compress
Assisting the client with preparation of a sitz bath The UAP can assist the client with hygiene issues and knows the principles of safety and comfort for this procedure. Monitoring the client, teaching techniques, and evaluating outcomes are nursing responsibilities.
The nurse is working in a hospice facility for patients with acquired immunodeficiency syndrome (AIDS). The facility is staffed with LPNs/LVNs and unlicensed assistive personnel (UAP). Which action will the nurse assign to the LPN/LVN? Assessing patients' nutritional needs and individualizing diet plans to improve nutrition 2. Collecting data about the patients' responses to medications used for pain and anorexia 3. Developing UAP training programs about how to lower the risk for spreading infections 4. Assisting patients with personal hygiene and other activities of daily living as needed
Collecting data about the patients' responses to medications used for pain and anorexia The collection of data used to evaluate the therapeutic and adverse effects of medications is included in LPN/LVN education and scope of practice. Assessment, planning, and developing teaching programs are more complex skills that require RN education. Assistance with hygiene and activities of daily living should be delegated to the UAP.
A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should the nurse intervene? 1. "You should avoid consumption of all forms of alcohol." 2. "Wear your medical alert bracelet at all times." 3. "Protect your loved one's airway during a seizure." 4. "It's OK to take over-the-counter medications."
"It's OK to take over-the-counter medications." A client with a seizure disorder should not take over-the-counter medications without consulting with the health care provider first. The other three statements are appropriate teaching points for clients with seizure disorders and their families.
The unlicensed assistive personnel (UAP) asks the nurse why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is the RN's best response? "The client's low phosphorus is probably due to malnutrition." 2. "The client is just worn out from not getting enough rest." 3. "The client's skeletal muscles are weak because of the low phosphorus." 4. "The client will do more for himself when his phosphorus level is normal."
"The client's skeletal muscles are weak because of the low phosphorus." A musculoskeletal manifestation of low phosphorus levels is generalized muscle weakness, which may lead to acute muscle breakdown (rhabdomyolysis). Phosphate is necessary for energy production in the form of adenosine triphosphate, and when not produced, leads to generalized muscle weakness. Although the other statements are true, they do not answer the UAP's question.
The nurse is working with an experienced unlicensed assistive personnel (UAP) and an LPN/LVN on the telemetry unit. A client who had an acute myocardial infarction 3 days ago has been reporting fatigue and chest discomfort when ambulating. Which nursing activity included in the care plan is best assigned to the LPN/LVN? 1. Administering nitroglycerin 0.4 mg sublingually if chest discomfort occurs during client activities 2. Monitoring pulse, blood pressure, and oxygen saturation before and after client ambulation 3. Teaching the client energy conservation techniques to decrease myocardial oxygen demand 4. Explaining the rationale for alternating rest periods with exercise to the client and family
1 Administration of nitroglycerin and appropriate client monitoring for therapeutic and adverse effects are included in LPN/LVN education and scope of practice. Monitoring of blood pressure, pulse, and oxygen saturation should be delegated to the UAP. Client teaching requires RN-level education and scope of practice.
These activities are included in the care plan for a 78-year-old patient admitted to the hospital with anemia caused by possible gastrointestinal bleeding. Which activity can the nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Obtaining stool specimens for fecal occult blood test (FOBT) 2. Having the patient sign a colonoscopy consent form 3. Giving the prescribed polyethylene glycol electrolyte solution 4. Checking for allergies to contrast dye or shellfish
1 An experienced UAP will have been taught how to obtain a stool specimen for the fecal occult blood test because this is a common screening test for hospitalized patients. Having the patient sign an informed consent form should be done by the health care provider who will be performing the colonoscopy. Administering medications and checking for allergies are within the scope of practice of licensed nursing staff.
The nurse is working in an outpatient clinic where many vascular diagnostic tests are performed. Which task associated with vascular testing is most appropriate to delegate to experienced unlicensed assistive personnel (UAP)? 1. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated 2. Checking blood pressure and pulse every 10 minutes in a client who is undergoing exercise testing 3. Obtaining information about allergies from a client who is scheduled for left leg contrast venography 4. Providing brief client teaching for a client who will undergo a right subclavian vein Doppler study
1 Measurement of ankle and brachial blood pressures for calculation is within the UAP's scope of practice. Calculating the ABI and any referrals or discussion with the client are the responsibility of the supervising RN. The other clients require more complex assessments or client teaching, which should be done by an experienced RN.
A client who had a stroke needs to be fed. What instruction should the nurse give to the unlicensed assistive personnel (UAP) who will feed the client? 1. Position the client sitting up in bed before he or she is fed. 2. Check the client's gag and swallowing reflexes. 3. Feed the client quickly because there are three more clients to feed. 4. Suction the client's secretions between bites of food.
1 Positioning the client in a sitting position decreases the risk of aspiration. The UAP is not trained to assess gag or swallowing reflexes. The client should not be rushed during feeding. A client who needs suctioning performed between bites of food is not handling secretions and is at risk for aspiration. Such a client should be assessed further before feeding.
Which change in vital signs would the nurse instruct the unlicensed assistive personnel to report immediately for a patient with hyperthyroidism? 1. Rapid heart rate 2. Decreased systolic blood pressure 3. Increased respiratory rate 4. Decreased oral temperature
1 The cardiac problems associated with hyperthyroidism include tachycardia, increased systolic blood pressure, and decreased diastolic blood pressure. Patients with hyperthyroidism also may have increased body temperature related to increased metabolic rate. Respiratory changes are usually not symptomatic of this condition.
When administering a blood transfusion to a patient, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Take the patient's vital signs before the transfusion is started. 2. Assure that the blood is infused within no more than 4 hours. 3. Ask the patient at frequent intervals about presence of chills or dyspnea. 4. Assist with double-checking the patient's identification and blood bag number.
1 UAP education and role includes obtaining vital signs, which will be reported to the RN prior to the initiation of the transfusion. Monitoring for transfusion reactions, adjusting transfusion rate, and assuring that the blood type and number are correct require critical thinking and should be done by the RN.
The patient is experiencing nausea and vomiting for which the health care provider has prescribed promethazine 12.5 mg orally four times a day as needed. Which patient care task would the nurse appropriately delegate to the unlicensed assistive personnel (UAP) before giving this drug? 1. Check the patient's temperature, blood pressure, and heart rate. 2. Auscultate the patient's abdomen for active bowel sounds. 3. Examine the patient's abdomen for any distention. 4. Ask the patient about constipation or difficulty swallowing.
1 Checking and recording vital signs for patients falls within the scope of practice for a UAP. Auscultating, examining, and asking questions about patient history remain within the scope of practice for a nurse and should not be delegated to UAP.
When an unexpected death occurs in the emergency department, which task is most appropriate to delegate to the unlicensed assistive personnel (UAP)? 1. Escorting the family to a place of privacy 2. Accompanying organ donor specialist to talk to family 3. Assisting with postmortem care 4. Helping the family to collect belongings
1 Postmortem care requires some turning, cleaning, lifting, and so on, and the UAP is able to assist with these duties. The RN should take responsibility for the other tasks to help the family begin the grieving process. In cases of questionable death, belongings may be retained for evidence, so the chain of custody would have to be maintained.
The nurse is preparing to care for a 6-year-old child who has just undergone allogenic stem cell transplantation. Which nursing tasks should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Stocking the child's room with standard personal protective equipment items 2. Teaching the child to perform thorough hand washing after using the bathroom 3. Reminding the child to wear a face mask outside of the hospital room 4. Assessing the child's oral cavity for signs and symptoms of infection 5. Talking to the family members about the methods to reduce risk of infection
13 Because all patient care staff members should be familiar with standard personal protective equipment, a UAP will be able to stock the room. Reminding the child to wear a face mask is also a task that can be done by a UAP, although the RN is responsible for the initial teaching. Initially teaching the child hand-washing technique, nursing assessments, and family education is within the scope of the registered nurse and not a UAP.
A 26-year-old gravida 1, para 1 patient who underwent cesarean section 24 hours ago tells the nurse that she is having some trouble breast feeding. Which tasks could be appropriately delegated to the unlicensed assistive personnel (UAP) on the postpartum floor? Select all that apply. 1. Providing the mother with an ordered abdominal binder 2. Assisting the mother with breast feeding 3. Taking the mother's vital signs 4. Checking the amount of lochia present 5. Assisting the mother with ambulation
135 The UAP could provide an abdominal binder, measure the vital signs of the patient, and assist her to ambulate. The RN would be responsible for evaluating the normality of the vital sign values. The UAP should be given parameter limits for vital signs and told to report values outside these limits to the RN. Assisting in breast feeding for a first-time mother is a very important nursing function because the RN needs to give consistent, evidence-based advice to enhance success at breast feeding. A common complaint of postpartum patients is inconsistent help with and advice on breast feeding. The RN should also be the one to check the amount of lochia because the evaluation requires nursing judgment. The use of the professionally educated RN to provide evidence-based and consistent information and assistance with breast feeding supports the Perinatal Core Measure of increasing the percentage of newborns who are fed breast milk only.
All of the following nursing care activities are included in the care plan for a 78-year-old man with Parkinson disease who has been referred to the home health agency. Which activities will the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Checking for orthostatic changes in pulse and blood pressure 2. Assessing for improvement in tremor after levodopa is given 3. Reminding the client to allow adequate time for meals 4. Monitoring for signs of toxic reactions to anti-Parkinson medications 5. Assisting the client with prescribed strengthening exercises 6. Adapting the client's preferred activities to his level of function
135 UAP education and scope of practice include checking pulse and blood pressure measurements. The nurse would be sure to instruct the UAP to report heart rate and blood pressure findings. In addition, UAPs can reinforce previous teaching or skills taught by the RN or personnel in other disciplines, such as speech or physical therapists. Evaluating client response to medications and developing and individualizing the plan of care require RN-level education and scope of practice.
The charge nurse in a long-term care facility that employs RNs, LPNs/LVNs, and unlicensed assistive personnel (UAP) has developed a plan for the ongoing assessment of all residents with a diagnosis of heart failure. Which activity included in the plan is most appropriate to assign to an LPN/LVN team member? 1. Weighing all residents with heart failure each morning 2. Listening to lung sounds and checking for edema each week 3. Reviewing all heart failure medications with residents every month 4. Updating activity plans for residents with heart failure every quarter
2 LPN/LVN education and scope of practice include data collection such as listening to lung sounds and checking for peripheral edema when caring for stable clients. Weighing the residents should be delegated to a UAP. Reviewing medications with residents and planning appropriate activity levels are nursing actions that require RN-level education and scope of practice.
The nurse is assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Assessing the patient's respiratory status every 4 hours 2. Taking vital signs and pulse oximetry readings every 4 hours 3. Checking the ventilator settings to make sure they are as prescribed 4. Observing whether the patient's tube needs suctioning every 2 hours
2 The UAP's educational preparation includes measuring vital signs, and an experienced UAP would have been taught and know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN.
The nurse is floated from the emergency department to the neurologic floor. Which action should the nurse delegate to the unlicensed assistive personnel (UAP) when providing nursing care for a client with a spinal cord injury? 1. Assessing the client's respiratory status every 4 hours 2. Checking and recording the client's vital signs every 4 hours 3. Monitoring the client's nutritional status, including calorie counts 4. Instructing the client how to turn, cough, and breathe deeply every 2 hours
2 The UAP's training and education covers measuring and recording vital signs. The UAP may help with turning and repositioning the client and may remind the client to cough and deep breathe, but he or she does not teach the client how to perform these actions. Assessing and monitoring clients require additional education and are appropriate to the scope of practice of professional nurses.
A patient in a long-term care facility who has anemia reports chronic fatigue and dizziness with minimal activity. Which nursing activity will the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Evaluating the patient's response to normal activities of daily living 2. Obtaining the patient's blood pressure and pulse with position changes 3. Determining which self-care activities the patient can do independently 4. Assisting the patient in choosing a diet that will improve strength
2 UAP education covers routine nursing skills such as assessment of vital signs. Evaluation, baseline assessment of patient abilities, and nutrition planning are activities appropriate to RN practice.
The charge nurse is assigning the nursing care of a patient who had a left below-the-knee amputation 1 day ago to an experienced LPN/LVN, who will function under an RN's supervision. What will the RN tell the LPN/LVN is the major focus for the patient's care today? 1. To attain pain control over phantom pain 2. To monitor for signs of sufficient tissue perfusion 3. To assist the patient to ambulate as soon as possible 4. To elevate the residual limb when the patient is supine
2 Monitoring for sufficient tissue perfusion is the priority at this time. Phantom pain is a concern but is more common in patients with above-the-knee amputations. Early ambulation is a goal, but at this time, the patient is more likely to be engaged in muscle-strengthening exercises. Elevating the residual limb on a pillow is controversial because it may promote knee flexion contracture.
When a client is being prepared for a colonoscopy procedure, which task is most suitable to delegate to unlicensed assistive personnel (UAP)? 1. Explaining the need for a clear liquid diet 2. Reinforcing "NPO" status 3. Administering laxatives as needed 4. Administering an enema to prepare the bowel
2. The UAP can reinforce dietary and fluid restrictions after the RN has explained the information to the client. It is also possible that the UAP can administer the enema; however, special training is required, and policies may vary among institutions. Medication administration should be performed by licensed personnel.
A patient diagnosed with hypertension has received the first dose of lisinopril. Which interventions will the RN delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Restrict the patient to bed rest for at least 12 hours. 2. Recheck the patient's vital signs every 4 to 8 hours. 3. Ensure that the patient's call light is within easy reach. 4. Keep the patient's bed in a supine position with all side rails up. 5. Remind the patient to rise slowly from the bed and sit before standing. 6. Assist the patient to get out of bed and use the bathroom. 7. Assess the patient for signs of dizziness.
2356 After the first dose of most antihypertensive drugs, dizziness is a common side effect. The patient should call for help when getting out of bed, and the call light should be within easy reach. The patient should rise slowly, sitting on the side of the bed before standing, and then can be assisted to the bathroom. The UAP's scope of practice includes these actions. Patients are not restricted to bed rest or kept in a supine (flat) position, and side rails are not all kept up for safety of the patient. Assessment is not within the scope of practice for a UAP. However, the RN could instruct the UAP to ask the patient about dizziness before and during ambulation and then report any dizziness immediately to the RN.
When the nurse is developing the plan of care for a home health client who has been discharged after a radical prostatectomy, which activities will be delegated to the home health aide? Select all that apply. 1. Monitoring the client for symptoms of urinary tract infection 2. Helping the client to connect the catheter to the leg bag 3. Checking the client's incision for appropriate wound healing 4. Assisting the client in ambulating for increasing distances 5. Helping the client shower at least every other day
245 Assisting with catheter care, ambulation, and hygiene are included in home health aide education and would be expected activities for this staff member. Client assessments are the responsibility of RN members of the home health care team.
Which actions can the school nurse delegate to an experienced unlicensed assistive personnel (UAP) who is working with a 7-year-old child with type 1 diabetes in an elementary school? Select all that apply. 1. Obtaining information about the child's usual insulin use from the parents 2. Administering oral glucose tablets when blood glucose level falls below 60 mg/dL (3.3 mmol/L) 3. Teaching the child about what foods have high carbohydrate levels 4. Obtaining blood glucose readings using the child's blood glucose monitor 5. Reminding the child to have a snack after the physical education class 6. Assessing the child's knowledge level about his or her type 1 diabetes
245 National guidelines published by the American Diabetes Association (ADA) indicate that administration of emergency treatment for hypoglycemia (e.g., glucose tablets), obtaining blood glucose readings, and reminding children about content they have already been taught by licensed caregivers are appropriate tasks for non-health care professional personnel such as teachers, paraprofessionals, and UAP. Assessments and education require more specialized education and scope of practice and should be done by the school nurse.
In the care of a client who has sustained recent blindness, which tasks would be appropriate to delegate to unlicensed assistive personnel (UAP)? Select all that apply. 1. Counseling the client to express grief or loss 2. Assisting the client with ambulating in the hall 3. Orienting the client to the surroundings 4. Encouraging independence 5. Obtaining supplies for hygienic care 6. Storing personal items to reduce clutter
25 Assisting the client with ambulating in the hall and obtaining supplies are within the scope of practice of the UAP. Counseling for emotional problems, orienting the client to the room, and encouraging independence require formative evaluation to gauge readiness, and these activities should be the responsibility of the RN. Storing items and rearranging furniture are inappropriate actions because the client needs be able to consistently locate objects in the immediate environment.
A client with Parkinson disease has a problem with decreased mobility related to neuromuscular impairment. The nurse observes the unlicensed assistive personnel (UAP) performing all of these actions. For which action must the nurse intervene? 1. Helping the client ambulate to the bathroom and back to bed 2. Reminding the client not to look at his feet when he is walking 3. Performing the client's complete bathing and oral care 4. Setting up the client's tray and encouraging the client to feed himself
3 Although all of these actions fall within the scope of practice for a UAP, the UAP should help the client with morning care as needed, but the goal is to keep this client as independent and mobile as possible. The client should be encouraged to perform as much morning care as possible. Assisting the client in ambulating, reminding the client not to look at his feet (to prevent falls), and encouraging the client to feed himself are all appropriate to the goal of maintaining independence.
The nurse is developing a standardized care plan for the postoperative care of clients undergoing cardiac surgery. The unit is staffed with RNs, LPN/LVNs, and unlicensed assistive personnel. Which nursing activity will need to be performed by RN staff members? 1. Removing chest and leg dressings on the second postoperative day and cleaning the incisions with antibacterial swabs 2. Reinforcing client and family teaching about the need to deep breathe and cough at least every 2 hours while awake 3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes 4. Administering oral analgesic medications as needed before helping the client out of bed on the first postoperative day
3 Development of plans for client care or teaching requires RN-level education and is the responsibility of the RN. Wound care, medication administration, assisting with ambulation, and reinforcing previously taught information are activities that can be assigned or delegated to other nursing personnel under the supervision of the RN.
The nurse is caring for a patient with carpal tunnel syndrome (CTS) who has been admitted for surgery. Which intervention should be delegated to the unlicensed assistive personnel (UAP)? 1. Initiating placement of a splint for immobilization during the day 2. Assessing the patient's wrist and hand for discoloration and brittle nails 3. Assisting the patient with daily self-care measures such as bathing and eating 4. Testing the patient for painful tingling in the four digits of the hand
3 Helping with activities of daily living (e.g. bathing, feeding) is within the scope of practice of UAPs. Placing a splint for the first time is appropriate to the scope of practice of physical therapists. Assessing and testing for paresthesia are not within the scope of practice of UAPs and is appropriate for professional nurses.
After a client has a seizure, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Documenting the seizure 2. Performing neurologic checks 3. Checking the client's vital signs 4. Restraining the client for protection
3 Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client's movements if necessary to prevent injury.
Which patient care action could the nurse delegate to unlicensed assistive personnel (UAP) after administering an inhaled anti-inflammatory drug to a patient with chronic obstructive pulmonary disease (COPD)? 1. Assess the patient's mouth for white-colored patches. 2. Teach the patient how to clean the inhaler and spacer. 3. Assist the patient to rinse the mouth with water or mouthwash. 4. Auscultate the patient's lungs for any changes in breath sounds.
3 Side effects of inhaled anti-inflammatory drugs include leaving a bad taste in the mouth after use and increased risk for oral candidiasis (thrush). Rinsing with water or mouthwash helps remove the drug from the mouth and reduce the bad taste and oral infection risk. 1, 2, and 4 are all actions that are within the scope of practice for the RN. Assisting the patient to rinse the mouth after administration of these drugs is within the scope of practice for a UAP.
A client is scheduled for patch testing to determine allergies to several substances. Which action associated with this test should the nurse delegate to unlicensed assistive personnel (UAP) working in the allergy clinic? 1. Explaining the purpose of the testing to the client 2. Examining the patch area for evidence of a reaction 3. Scheduling a follow-up appointment for the client in 2 days 4. Monitoring the client for anaphylactic reactions to the testing
3 Scheduling a follow-up appointment for the client is within the legal scope of practice and training for the UAP role. Client teaching, assessment for positive skin reactions to the test, and monitoring for serious allergic reactions are appropriate to the education and practice role of licensed nursing staff.
Emergency medical services has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, the nurse notes unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the unlicensed assistive personnel (UAP)? 1. Performing chest compressions 2. Initiating bag-valve mask ventilation 3. Assisting with oral intubation 4. Placing the defibrillator pads
3 UAPs are trained in basic cardiac life support and can perform chest compressions. The use of the bag-valve mask requires practice, and usually a respiratory therapist will perform this function. The nurse or the respiratory therapist should provide assistance as needed during intubation. The defibrillator pads are clearly marked; however, placement should be done by the RN or health care provider because of the potential for skin damage and electrical arcing.
In the care of a client with gastroesophageal reflux disease, which task would be appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Sharing successful strategies for weight reduction 2. Encouraging the client to express concerns about lifestyle modification 3. Reminding the client not to lie down for 2 to 3 hours after eating 4. Explaining the rationale for eating small frequent meals
3. Reminding the client to follow through on advice given by the nurse is an appropriate task for the UAP. The RN should take responsibility for teaching rationale, discussing strategies for the treatment plan, and assessing client concerns.
A patient with a diagnosis of sleep apnea has a problem with sleep deprivation related to a disrupted sleep cycle. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Discussing weight-loss strategies such as diet and exercise with the patient 2. Teaching the patient how to set up the bilevel positive airway pressure (BiPAP) machine before sleeping 3. Reminding the patient to sleep on his side instead of his back 4. Administering modafinil to promote daytime wakefulness
3. The UAP can remind patients about actions that have already been taught by the nurse and are part of the patient's plan of care. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can administer or assign medication administration to an LPN/LVN.
The nurse is caring for a client who was recently admitted for severe diverticulitis. Which task is appropriate to delegate or assign for the care of this client? 1. Tell the unit secretary to call radiology and schedule a barium enema. 2. Ask the LPN/LVN to give as needed (PRN) laxatives when the client reports constipation. 3. Instruct the nursing student to help the client ambulate up and down the hall. 4. Tell unlicensed assistive personnel to save a stool specimen to test for occult blood.
4 Diverticulitis can cause chronic or severe bleeding, so if there is no obvious blood in the stool, the stool may be tested for occult blood. A barium enema is not usually ordered because of the danger of perforation. Laxatives and ambulation increase intestinal motility and are to be avoided in the initial phase of treatment. If a barium enema, PRN laxative, or ambulation are prescribed, the nurse should check with the health care provider before delegating these interventions.
An 18-month-old child has oral mucositis secondary to chemotherapy. Which task should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Reporting evidence of severe mucosal ulceration 2. Assisting the child in swishing and spitting mouthwash 3. Assessing the child's ability and willingness to drink through a straw 4. Feeding the child a bland, moist, soft diet
4 Helping the child to eat is within the scope of responsibilities for a UAP. Assessing ability and willingness to drink and checking for extent of mucosal ulceration is the responsibility of an RN. An 18-month-old child is not able to swish and spit, which could result in swallowing the mouthwash. Mouthwash is not intended for swallowing because it can contain alcohol and other ingredients not safe for ingestion.
A patient with Hodgkin lymphoma who is receiving radiation therapy to the groin area has skin redness and tenderness in the area being irradiated. Which nursing activity should the nurse delegate to the unlicensed assistive personnel (UAP) caring for the patient? 1. Checking the skin for signs of redness or peeling 2. Assisting the patient in choosing appropriate clothing 3. Explaining good skin care to the patient and family 4. Cleaning the skin over the area daily with a mild soap
4 Skin care is included in UAP education and job description. Assessment and patient teaching are more complex tasks that should be delegated to RNs. Because the patient's clothes need to be carefully chosen to prevent irritation or damage to the skin, the RN should assist the patient with this.
A client's potassium level is 6.7 mEq/L (6.7 mmol/L). Which intervention should the nurse delegate to the first-year student nurse whom he or she is supervising? Administer sodium polystyrene sulfonate 15 g orally. 2. Administer spironolactone 25 mg orally. 3. Assess the electrocardiogram (ECG) strip for tall T waves. 4. Administer potassium 10 mEq (10 mmol/L) orally.
Administer sodium polystyrene sulfonate 15 g orally. The client's potassium level is high (normal range is 3.5 to 5 mEq/L or 3.5 to 5 mmol/L). Sodium polystyrene sulfonate removes potassium from the body through the gastrointestinal system. Spironolactone is a potassium-sparing diuretic that may cause the client's potassium level to go even higher. A KCl supplement can also raise the potassium level even higher. The beginning nursing student does not have the skill to assess ECG strips.
A resident in a long-term care facility who has venous stasis ulcers is treated with an Unna boot. Which nursing activity included in the resident's care is best for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Teaching family members the signs of infection 2. Monitoring capillary perfusion once every 8 hours 3. Evaluating foot sensation and movement each shift 4. Assisting the client in cleaning around the Unna boot
Assisting the client in cleaning around the Unna boot
A patient has chronic obstructive pulmonary disease (COPD). Which intervention for airway management should the nurse delegate to the unlicensed assistive personnel (UAP)? Assisting the patient to sit up on the side of the bed 2. Instructing the patient to cough effectively 3. Teaching the patient to use incentive spirometry 4. Auscultating breath sounds every 4 hours
Assisting the patient to sit up on the side of the bed Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of UAPs. Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate to the scope of practice of licensed nurses.
The nurse is caring for a patient with esophageal cancer. Which task could be delegated to unlicensed assistive personnel (UAP)? Assisting the patient with oral hygiene 2. Observing the patient's response to feedings 3. Facilitating expression of grief or anxiety 4. Initiating daily weights
Assisting the patient with oral hygiene Oral hygiene is within the scope of duties of the UAP. It is the responsibility of the nurse to observe response to treatments and to help the patient deal with loss or anxiety. The UAP can be directed to weigh the patient but should not be expected to know when to initiate that measurement.
The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? . Chest tube drainage of 10 to 15 mL/hr 2. Continuous bubbling in the water-seal chamber 3. Reports of pain at the chest tube site 4. Chest tube dressing dated yesterday
Continuous bubbling in the water-seal chamber Continuous bubbling indicates an air leak that must be identified. With the health care provider's (HCP's) order, an RN can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion, which will require the RN to notify the HCP. If the air bubbling does not stop when the RN applies the padded clamp, the air leak is between the clamp and the drainage system, and the RN must assess the system carefully to locate the leak. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. The patient's reports of pain need to be assessed and treated. This is important but is not as urgent as investigating a chest tube leak.
A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would the nurse give the unlicensed assistive personnel (UAP) who will help the patient with activities of daily living (ADLs)? Select all that apply. Use a lift sheet when moving and positioning the patient in bed. 2. Use an electric razor when shaving the patient each day. 3. Use a soft-bristled toothbrush or tooth sponge for oral care. 4. Use a rectal thermometer to obtain a more accurate body temperature. 5. Be sure the patient's footwear has a firm sole when the patient ambulates. 6. Assess the patient for any signs or symptoms of bleeding.
Correct Answer: 1,2,3,5 While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). Assessment of patients is within the scope of practice for professional nurses. All of the other instructions are appropriate for the UAP when caring for a patient receiving anticoagulants.
Which actions should the nurse delegate to an experienced unlicensed assistive personnel (UAP) when caring for a client with a thrombotic stroke who has residual left-sided weakness? Select all that apply. 1. Assisting the client to reposition every 2 hours 2. Reapplying pneumatic compression boots 3. Reminding the client to perform active range-of-motion (ROM) exercises 4. Assessing the extremities for redness and edema 5. Setting up meal trays and assisting with feeding 6. Using a lift to assist the client up to a bedside chair
Correct Answer: 1,2,3,5,6 An experienced UAP would know how to reposition the client, reapply compression boots, and feed a client, and would remind the client to perform activities the client has been taught to perform. UAPs are also trained to use a client lift to get clients into or out of bed. Assessing for redness and swelling (signs of deep vein thrombosis) requires additional education and skill, appropriate to the professional nurse.
In the care of a patient with neutropenia, what tasks should the nurse instruct unlicensed assistive personnel (UAP) to perform? Select all that apply. Taking vital signs every 4 hours 2. Reporting temperature of more than 100.4°F (38°C) 3. Assessing for sore throat, cough, or burning with urination 4. Gathering the supplies to prepare the room for protective isolation 5. Reporting superinfections, such as candidiasis 6. Practicing good hand-washing technique
Correct Answer: 1,2,4,6 Measuring vital signs and reporting on specific parameters, practicing good hand washing, and gathering equipment are within the scope of duties for a UAP. Assessing for symptoms of infections and superinfections is the responsibility of the RN.
The nurse is acting as preceptor for a newly-graduated RN during the second week of orientation. The nurse would assign and supervise the new RN to provide nursing care for which patients? Select all that apply. A 38-year-old patient with moderate persistent asthma awaiting discharge 2. A 63-year-old patient with a tracheostomy needing tracheostomy care every shift 3. A 56-year-old patient with lung cancer who has just undergone left lower lobectomy 4. A 49-year-old patient just admitted with a new diagnosis of esophageal cancer 5. A 76-year-old patient newly diagnosed with type 2 diabetes 6. A 69-year-old patient with emphysema to be discharged tomorrow
Correct Answer: 1,2,6 The new RN is at an early point in orientation. The most appropriate patients to assign to the new RN are those in stable condition who require routine care. The patient with the lobectomy will require the care of an experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. The newly diagnosed diabetic patient will need much teaching as well as careful monitoring. As the new nurse advances through orientation, the preceptor will want to work with him or her in providing care for patients with more complex needs.
The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to a new-graduated RN. Which actions can the new-graduate RN delegate to the unlicensed assistive personnel (UAP)? Select all that apply. Providing oral care every 3 to 4 hours 2. Monitoring for indications of dehydration 3. Administering 0.45% saline by IV line 4. Record urine output when client voids 5. Assessing daily weights for trends 6. Help the client change position every 2 hours
Correct Answer: 1,4,6 Providing oral care, assisting clients to reposition, and recording urine output are within the scope of practice of the UAP. Monitoring and assessing clients, as well as administering IV fluids, require the additional education and skills of the RN.
Which actions should the nurse delegate to an unlicensed assistive personnel (UAP) for the client with diabetic ketoacidosis? Select all that apply. Checking fingerstick glucose results every hour 2. Recording intake and output every hour 3. Measuring vital signs every 15 minutes 4. Assessing for indicators of fluid imbalance 5. Notifying the provider of changes in glucose level 6. Assisting the client to reposition every 2 hours
Correct Answer: 2,3,6 The UAP's training and education includes how to measure vital signs, record intake and output, and reposition clients. Performing fingerstick glucose checks and assessing clients requires additional education and skill, as possessed by licensed nurses. Notifying the provider of glucose changes is within the scope of practice for licensed nurses. Some facilities may train experienced UAPs to perform fingerstick glucose checks and change their role descriptions to designate their new skills, but this task is beyond the normal scope of practice of a UAP.
The nurse is caring for a patient after thoracentesis. Which actions can be delegated from the nurse to the unlicensed assistive personnel (UAP)? Select all that apply. Assess puncture site and dressing for leakage. 2. Check vital signs every 15 minutes for 1 hour. 3. Auscultate for absent or reduced lung sounds. 4. Remind the patient to take deep breaths. 5. Take the specimens to the laboratory. 6. Teach the patient symptoms of pneumothorax.
Correct Answer: 2,4,5 Checking vital signs, carrying specimens to the lab, and reminding patients about what has already been taught are actions that are within the scope of practice for UAP. Assessing and teaching patients requires additional knowledge and training that is within the scope of practice for professional nurses.
Which infection control activity should the charge nurse delegate to an experienced unlicensed assistive personnel (UAP)? Screening clients for upper respiratory tract symptoms 2. Asking clients about the use of immunosuppressant medications 3. Demonstrating correct hand washing to the clients' visitors 4. Disinfecting blood pressure cuffs after clients are discharged
Disinfecting blood pressure cuffs after clients are discharged The UAP can follow agency policy to disinfect items that come in contact with intact skin (e.g., blood pressure cuffs) by cleaning with chemicals such as alcohol. Teaching and assessment for upper respiratory tract symptoms or use of immunosuppressants require more education and a broader scope of practice, and these tasks should be performed by licensed nurses.
The nurse is working with an unlicensed assistive personnel (UAP) to care for a client who has had a right breast lumpectomy and axillary lymph node dissection. Which nursing action can be delegated to the UAP? 1. Teaching the client why blood pressure measurements are taken on the left arm 2. Elevating the client's arm on two pillows to promote lymphatic drainage 3. Assessing the client's right arm for lymphedema 4. Reinforcing the dressing if it becomes saturated
Elevating the client's arm on two pillows to promote lymphatic drainage Positioning the client's arm is a task within the scope of practice for UAP working on a surgical unit. Client teaching and assessment are RN-level skills. The RN should reinforce dressings as necessary because this requires assessment of the surgical site and possible communication with the surgeon.
The unlicensed assistive personnel (UAP) is assisting with feeding for a patient with severe end-stage chronic obstructive pulmonary disease (COPD). Which instruction will the nurse provide the UAP? Encourage the patient to eat foods that are high in calories and protein. 2. Feed the patient as quickly as possible to prevent early satiety. 3. Offer lots of fluids between bites of food. 4. Try to get the patient to eat everything on the tray.
Encourage the patient to eat foods that are high in calories and protein. Patients with COPD often have food intolerance, nausea, early satiety (feeling too "full" to eat), poor appetite, and meal-related dyspnea. The increased work of breathing raises calorie and protein needs, which can lead to protein-calorie malnutrition. Urging the patient to eat high-calorie, high-protein foods can be done by the UAP after the nurse has taught the patient about the importance of this strategy to prevent weight loss. Feeding the patient too rapidly will tire him or her. If early satiety is a problem, avoid fluids before or during the meal or provide smaller, more frequent meals.
The nurse is responsible for the care of a postoperative patient with a thoracotomy. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? Instructing the patient to alternate rest and activity periods 2. Encouraging, monitoring, and recording nutritional intake 3. Monitoring cardiorespiratory response to activity 4. Planning activities for periods when the patient has the most energy
Encouraging, monitoring, and recording nutritional intake The UAP's training includes how to monitor and record intake and output. After the nurse has taught the patient about the importance of adequate nutritional intake for energy, the UAP can remind and encourage the patient to take in adequate nutrition. Instructing patients and planning activities require more education and skill and are appropriate to the RN's scope of practice. Monitoring the patient's cardiovascular response to activity is a complex process requiring additional education, training, and skill, and falls within the RN's scope of practice.
A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Teaching the client and family members about means to prevent transmission of VRE 2. Communicating with other departments when the client is transported for ordered tests 3. Implementing contact precautions when providing care for the client 4. Monitoring the results of ordered laboratory culture and sensitivity tests
Implementing contact precautions when providing care for the client All hospital personnel who care for the client are responsible for correct implementation of contact precautions. The other actions should be carried out by licensed nurses, whose education covers monitoring of laboratory results, client teaching, and communication with other departments about essential client data.
Which specific instruction does the charge nurse give the unlicensed assistive personnel (UAP) helping to provide care for a client who is at risk for metabolic acidosis? Check to see that the client keeps his oxygen in place at all times. 2. Inform the nurse immediately if the client's respiratory rate and depth increases. 3. Record any episodes of reflux or constipation. 4. Keep the client's ice water pitcher filled at all times.
Inform the nurse immediately if the client's respiratory rate and depth increases. If acidosis is metabolic in origin, the rate and depth of breathing increase as the hydrogen ion level rises. Breaths are deep and rapid and not under voluntary control, a pattern called Kussmaul respiration. The client may not require oxygen. Although it's important to record reflux and constipation, this is not related to metabolic acidosis nor is keeping the water pitcher full specific to this condition.
The nurse is the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with acute respiratory distress syndrome (ARDS) who has just been intubated in preparation for mechanical ventilation. The preceptor observes the RN performing all of these actions. For which action must the preceptor intervene immediately? Assesses for bilateral breath sounds and symmetrical chest movement 2. Uses an end-tidal carbon dioxide detector to confirm endotracheal tube (ET) position 3. Marks the tube 1 cm from where it touches the incisor tooth or nares 4. Orders chest radiography to verify that tube placement is correct
Marks the tube 1 cm from where it touches the incisor tooth or nares The ET should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after ET placement. The priority at this time is to verify that the tube has been correctly placed. Use of an end-tidal carbon dioxide detector is the gold standard for evaluating and confirming ET position in patients who have adequate tissue perfusion.
A client has severe pain and bladder distention related to urinary retention and possible obstruction. An experienced unlicensed assistive personnel (UAP) states that she received training in indwelling catheter insertion at a previous job. What task can be delegated to this UAP? Assessing the bladder distention and the pain associated with urinary retention 2. Inserting the indwelling catheter after verifying her knowledge of sterile technique 3. Evaluating the relief of pain and bladder distention after the catheter is inserted 4. Measuring the urine output after the catheter is inserted and obtaining a specimen
Measuring the urine output after the catheter is inserted and obtaining a specimen Measuring output and obtaining a specimen are within the scope of practice of the UAP. Insertion of the indwelling catheter in this client should be done by an experienced RN because clients with obstruction and retention are usually very difficult to catheterize, and the nurse must evaluate the pain response during the procedure. The UAP's knowledge of sterile technique or catheter insertion is not the issue.
For a patient with hyperthyroidism, which task should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Instructing the patient to report any occurrence of palpitations, dyspnea, vertigo, or chest pain 2. Monitoring the apical pulse, blood pressure, and temperature every 4 hours 3. Drawing blood to measure levels of thyroid-stimulating hormone, triiodothyronine, and thyroxine 4. Teaching the patient about side effects of the drug propylthiouracil
Monitoring the apical pulse, blood pressure, and temperature every 4 hours Monitoring vital signs and recording their values are within the education and scope of practice of UAPs. An experienced UAP should have been taught how to monitor the apical pulse. However, a nurse should observe the UAP to be sure that the UAP has mastered this skill. Instructing and teaching patients, as well as performing venipuncture to obtain laboratory samples, are more suited to the education and scope of practice of licensed nurses. In some facilities, an experienced UAP may perform venipuncture, but only after special training.
A patient with chronic obstructive pulmonary disease (COPD) has rapid shallow respirations. Which is an appropriate action to assign to the experienced LPN/LVN under RN supervision? Observing how well the patient performs pursed-lip breathing 2. Planning a nursing care regimen that gradually increases activity tolerance 3. Assisting the patient with basic activities of daily living (ADLs) 4. Consulting with the physical therapy department about reconditioning exercises
Observing how well the patient performs pursed-lip breathing Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to UAPs. Planning and consulting require additional education and skills, appropriate to the RN's scope of practice.
A patient with chronic obstructive pulmonary disease (COPD) tells the unlicensed assistive personnel (UAP) that he did not get his annual flu shot this year and has not had a pneumonia vaccination. Which vital sign change will be most important for the nurse to instruct the UAP to report? . Blood pressure of 152/84 mm Hg 2. Respiratory rate of 27 breaths/min 3. Heart rate of 92 beats/min 4. Oral temperature of 101.2°F (38.4°C)
Oral temperature of 101.2°F (38.4°C)
A patient with chronic obstructive pulmonary disease (COPD) tells the unlicensed assistive personnel (UAP) that he did not get his annual flu shot this year and has not had a pneumonia vaccination. Which vital sign change will be most important for the nurse to instruct the UAP to report? 1. Blood pressure of 152/84 mm Hg 2. Respiratory rate of 27 breaths/min 3. Heart rate of 92 beats/min 4. Oral temperature of 101.2°F (38.4°C)
Oral temperature of 101.2°F (38.4°C) A patient who did not have the pneumonia vaccination or flu shot is at increased risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection, which may be respiratory in origin. All of the other vital sign values are slightly elevated and should be followed up on but are not a cause for immediate concern.
The client has fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to unlicensed assistive personnel (UAP)? Administering IV fluids as prescribed by the physician 2. Providing straws and offering fluids between meals 3. Developing a plan for added fluid intake over 24 hours 4. Teaching family members to assist the client with fluid intake
Providing straws and offering fluids between meals UAPs can reinforce additional fluid intake when it is part of the care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice of an RN.
The nurse is initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should the nurse delegate to the unlicensed assistive personnel (UAP)? Teaching the patient about the importance of adequate fluid intake and hydration 2. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed 3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake 4. Encouraging the patient to take a deep breath, hold it for 2 seconds, and then cough two or three times in succession
Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake UAPs can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic UAP. However, an experienced UAP could assist the patient with positioning after the UAP and the patient had been taught the proper technique. UAPs would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill and is within the scope of practice of the RN.
The nurse is supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause the nurse to intervene? Suctioning the tracheostomy tube before performing tracheostomy care 2. Removing old dressings and cleaning off excess secretions 3. Removing the inner cannula and cleaning using standard precautions 4. Replacing the inner cannula and cleaning the stoma site
Removing the inner cannula and cleaning using standard precautions When tracheostomy care is performed, a sterile field is set up, and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate.
For a patient who is experiencing side effects of radiation therapy, which task would be the most appropriate to delegate to unlicensed assistive personnel (UAP)? Helping the patient to identify patterns of fatigue 2. Recommending participation in a walking program 3. Reporting the amount and type of food consumed from the tray 4. Checking the skin for redness and irritation after the treatment
Reporting the amount and type of food consumed from the tray The UAP can observe the amount that the patient eats (or what is gone from the tray) and report to the nurse. Assessing patterns of fatigue and skin reaction is the responsibility of the RN. The initial recommendation for exercise should come from the health care provider.
A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse assesses the client, which finding would the nurse instruct the student to report immediately? Respiratory rate of 8 to 10 breaths/min 2. Decrease in pain level from 6 to 2 (on a scale of 1 to 10) 3. Request by the client that the room door be closed 4. Heart rate of 90 to 100 beats/min
Respiratory rate of 8 to 10 breaths/min A decreased respiratory rate indicates respiratory depression, which also puts the client at risk for respiratory acidosis. All of the other findings are important and should be reported to the RN, but the respiratory rate demands urgent attention.
The nurse manager in a public health department is implementing a plan to reduce the incidence of infection with human immunodeficiency virus (HIV) in the community. Which nursing action will be delegated to unlicensed assistive personnel (UAP) working for the agency? Supplying injection drug users with sterile injection equipment such as needles and syringes 2. Interviewing patients about behaviors that indicate a need for annual HIV testing 3. Teaching high-risk community members about the use of condoms in preventing HIV infection 4. Assessing the community to determine which population groups to target for education
Supplying injection drug users with sterile injection equipment such as needles and syringes Supplying sterile injection supplies to patients who are at risk for HIV infection can be done by staff members with UAP education. Assessing for high-risk behaviors, education, and community assessment are RN-level skills.
A patient has a fractured femur. Which finding would the nurse instruct the unlicensed assistive personnel (UAP) to report immediately? 1. The patient reports pain. 2. The patient appears confused. 3. The patient's blood pressure is 136/88 mm Hg. 4. The patient voided using the bedpan.
The patient appears confused. Fat embolism syndrome is a serious complication that often results from fractures of long bones. Its earliest manifestation is altered mental status caused by a low arterial oxygen level. The nurse would want to know about and treat the pain, but it is not life threatening. The nurse would also want to know about the blood pressure and the patient's voiding; however, this information is not urgent to report.
The home health nurse is interviewing an older client with a history of mild heart failure and rheumatoid arthritis. The client reports "feeling pretty good, except for the pain and stiffness in my joints when I first get out of bed." Which member of the health care team would be the most appropriate to aid in the client's report of pain Health care provider to review the dosage and frequency of pain medication 2. Physical therapist for evaluation of function and possible exercise therapy 3. Social worker to locate community resources for complementary therapy 4. Unlicensed assistive personnel to help client with a warm shower in the morning
Unlicensed assistive personnel to help client with a warm shower in the morning One of the common features of rheumatoid arthritis is joint pain and stiffness when first rising. This usually resolves over the course of the day. A nonpharmaceutical measure is to take a warm shower (or apply warm packs to joints if pain is limited to one or two joints). If pain worsens, then the nurse may elect to contact other members of the health care team for additional interventions.
The nurse observes the unlicensed assistive personnel (UAP) performing all of these interventions for a patient with carpal tunnel syndrome (CTS). Which action requires that the nurse intervene immediately? 1. Arranging the patient's lunch tray and cutting his meat 2. Providing warm water and assisting the patient with his bath 3. Replacing the patient's splint in hyperextension position 4. Reminding the patient not to lift very heavy objects
When a patient with CTS has a splint to immobilize the wrist, the wrist is placed either in the neutral position or in slight extension, not hyperextension. The other interventions are correct and are within the scope of practice of a UAP. UAPs may remind patients about elements of their care plans such as avoiding heavy lifting.
The nurse is caring for a patient with risk for kidney disease for whom a urinalysis has been ordered. What time would the nurse instruct the unlicensed assistive personnel is best to collect this sample? 1. With first morning void 2. Before any meal 3. At bedtime 4. Immediately
With first morning void Urinalysis is a part of any complete physical examination and is especially useful for patients with suspected kidney or urologic disorders. Ideally, the urine specimen is collected at the morning's first voiding. Specimens obtained at other times may be too dilute.
