Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel UAP )? Quizlet?
fundamentals (NCLEX Questions) Show
Terms in this set (15)The RN cannot delegate checking the crash cart Collecting a urine sample Other sets by this creator1. 32 year old female receiving her first dose of Ancef 1g IVPB prior to surgery calls to complain of total body itching a rash and a 'funny' feeling on her tongue 2. 98 year old male in the bathroom yelling to be brought back into bed 3. 22 year old male with insulin dependent diabetes requires his blood glucose checked prior to sliding scale insulin. Breakfast trays arrive at 0730. 4. 56 year old female on call at 0730 for a cholecystectomy needs her pre-op meds and you find that her surgical consent form is missing. 5. The husband of an anxious S/P radical mastectomy patient is requesting pain meds for his wife. 6. Your favorite surgeon of all time is requesting assistance with a first time dressing change on a 36 year old female S/P colon resection. 7. 78 year old female is watching television and cheering you on because she is a retired nurse and is just happy to know she is no longer in nursing. A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy? Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by. Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization. Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself. Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure. Roles and responsibilities of PNs vary by state and facility practice. Most commonly, PNs are not able to provide IV treatments or perform assessments. PNs are qualified to give oral meds, perform client care activities, and collect vital signs. A client is on neutropenic precautions. What role in client care would be appropriate for the practical nurse (PN)? Administer 500 mg oral Vancomycin. NOT: Screen visitors for communicable diseases. Determine which isolation precautions to initiate. It is important for the RN to know and understand the scope of practice of the PN when delegating nursing actions to the PN. Complete assessments and formulation of nursing plans should be left to the RN to complete. PNs may auscultate breath sounds, use sterile technique to suction established tracheostomies, and administer ophthalmic medications. A practical nurse (PN) and a registered nurse (RN) are assigned a group of clients on a nursing care unit. Which actions does the RN delegate to the PN? Select All That Apply Administer ophthalmic medications. Auscultate a client's breath sounds. Suction an established tracheostomy. NOT: Formulate the nursing care plan. Delegation involves the registered nurse passing the responsibility of completion of a task another individual whose scope of practice includes the task. The nurse who delegated the task still remains accountable. The nurse first assesses and determines priority needs and determination of eligible staff for completion
of the task. In order to delegate, registered nurses need to be aware of Nurse Practice Acts in the location of practice and scope of practice for individuals to whom the nurse is delegating. The nursing process cannot be delegated. A registered nurse provides care for a critically ill client and is unable to leave the client. A UAP obtains noon vital signs for another assigned client and reports the findings to the registered nurse. Which action does the nurse take? (See exhibit.) Select All That
Apply Ask the PN to apply oxygen via nasal cannula at 2 L/min. NOT: Ask the UAP to apply oxygen via nasal
cannula at 2 L/min. Complete care needs of current client, then assess second client's respiratory status. Report to the second client's room and assess respiratory status. According the the NCLEX-PN test plan, PNs perform the following: With required training, the PN can administer IV medications after the first dose has been administered by an RN. Any client expecting to receive IV medications should be managed by the RN. Stable clients are appropriate assignments for PNs, because they are generally on PO medications or IV medications that have been first administered by an RN. Newly admitted clients require an assessment and frequent monitoring from the RN until they are determined to be stable, so they are not appropriate assignments for care management by the PN. A charge nurse assigns a practical nurse (PN) to six clients. The team includes a registered nurse (RN), a PN, and an unlicensed assistive personnel (UAP). Which actions by the RN are correct? Select All That Apply Instruct the UAP to obtain vital signs on all assigned clients at 0800 and 1200. Inform the PN of the need to measure hourly output from the chest tube. Instruct the PN to administer 0800 PO medications to all assigned clients. NOT: Observe the PN administering newly ordered IV pain medication to
a client. The RN must be mindful of appropriate delegation to various individuals working on the unit with the nurse. Assessment, planning, and evaluation should not be delegated to anyone other than the RN. Assistance with activities of daily living may be delegated to the UAP, not the PN. Observation of a client is within the scope of the PN and may be delegated as appropriate. A registered nurse (RN) works with a practical nurse (PN) and unlicensed assistive personnel (UAP) to provide care for a client with emphysema and ineffective airway clearance. Which task is best assigned to the PN? Observe the client's technique of airway clearance activities. NOT: Evaluate the
efficacy of the nursing care plan. Assess the client's knowledge of airway clearance techniques. Delegation involves the RN passing the responsibility of completion of a task to another individual whose scope of practice includes the task.
The nurse who delegated the task still remains accountable. The nurse first assesses and determines priority needs and eligible staff for completion of the task. A registered nurse (RN) delegates administration of a pain medication to a practical nurse (PN). The client has surgical incision pain of 8/10. After completion of the task, which action does the RN take? Follow up with the PN within 30 minutes of delegating this assigned task. NOT: Document the administration of the pain medication in the client's health record. Supervise the PN while administering the medication. Delegation involves the RN passing the responsibility of completion of a task to another individual whose scope of practice includes the task. The nurse who delegated the task still remains accountable. The nurse first assesses and determines priority needs and eligible staff for completion of the task. In order to delegate, RNs need to be aware of the scope of practice of individuals to whom they are delegating. The nursing process cannot be delegated. A registered nurse (RN) receives a new admission who requires immediate and ongoing attention. The RN requests assistance for tasks with the remaining assigned clients. Which tasks require completion by an RN or a practical nurse (PN)? Select All That Apply Insertion of an indwelling urinary catheter for a client unable to void. Cleaning and suctioning
an endotracheal tube Providing a client with instructions prior to discharge NOT: Obtaining vital signs on a 1-day post appendectomy client According
the the NCLEX-PN test plan, practical nurses perform the following: A registered nurse (RN) works with a practical nurse (PN) on a medical-surgical unit. Which tasks does the RN delegate to the PN? Select All That Apply Administer the first dose of ibuprofen 600 mg PO to a client for pain. Perform a urinary catheterization on a client unable to void. Administer the third dose of cefazolin 2 g by IV piggyback. NOT: Initiate an IV infusion on a newly admitted client. Unlicensed assistive personnel can perform many non-invasive tasks such as ambulation, activities of daily living, and the care of stable clients. Practical nurses (PNs) may do other invasive tasks, such as urinary catheter irrigation. PNs are not able to complete all tasks that registered nurses can, as they do not have the same knowledge base.When delegating, the nurse must follow the five rights of delegation: right task, right circumstance, right person, right direction and communication, and right supervision and evaluation. Responsibility always remains with the nurse as the licensed professional, even when tasks are delegated. Additionally, acts within the scope of practice for all healthcare providers may vary by state policy and should be the basis for delegation. A nurse cares for a client with a prescription for irrigation of an indwelling urinary catheter. The nurse knows this task can be delegated to which personnel? A practical nurse NOT: An unlicensed assistive personnel A radiology technician According the the NCLEX-PN test plan, PNs perform the following: With required training, the PN can administer IV medications after the first dose has been administered by a registered nurse. Any client expecting to receive IV medications should be managed by the RN. Stable patients are appropriate assignments for PNs, because they are generally on PO medications or IV medications that have been first administered by an RN. Newly admitted clients require an assessment from an RN and frequent monitoring until they are determined to be stable and, therefore, are not appropriate assignments for care management by a PN. A charge nurse delegates assignments for the oncoming shift with a registered nurse (RN) and a practical nurse (PN). Which assignments are appropriate for the PN? Select All That Apply A toddler-aged client 1-day post-surgical repair for clubfoot An adolescent client two days post-appendectomy NOT: An older adult client transferred from critical care after extubation A young adult client with ovarian cancer admitted for chemotherapy According to the NCLEX-PN test plan, PNs perform the following: In some settings with required training, the PN can administer IV medications after the first dose has been administered by a registered nurse. A registered nurse (RN) delegates care to a practical nurse (PN) on a medical-surgical unit. The nurse manager rounds on the unit. Which action observed being performed by the PN would require the nurse manager to discuss appropriate delegation with the RN? Select All That Apply Assessment of a newly admitted client from the surgical recovery room NOT: Administration
of oxycodone, two tabs PO for post-surgical pain management Changing the abdominal dressing of a client with a wound drain three days post-surgery Removing the staples from a back surgical incision prior to discharge home What task is the most appropriate to delegate to the unlicensed assistive personnel UAP )?In general, simple, routine tasks such as making unoccupied beds, supervising patient ambulation, assisting with hygiene, and feeding meals can be delegated. But if the patient is morbidly obese, recovering from surgery, or frail, work closely with the UAP or perform the care yourself.
Which task may the nurse delegate to unlicensed assistive personnel UAP?Routine tasks, such as taking vital signs, supervising ambulation, bed making, assisting with hygiene, and activities of daily living, can be delegated to an experienced UAP. The charge nurse appropriately delegates the routine task of feeding to the UAP.
Which tasks are appropriate for the unlicensed assistive personnel?Typical UAP Tasks
Common ADLs include bathing and grooming, feeding, dressing, toileting, ambulating, and continence.
Which of these activities can the nurse assign to an unlicensed assistive personnel UAP )?Unlicensed assistive personnel (UAP) can perform a number of delegated nursing tasks, such as emptying an indwelling urinary catheter bag, applying moisture barrier cream after peri-care, assisting a client to the bathroom and helping a client shave with an electric razor.
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