Question 1

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.

Accepted Answer

11ecbb05_cb97_6584_b433_9ffea401b4a7_MD0009_00 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 A, D, and E). (Option B) 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 C) 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. Educational objective: Emptying a urinary drainage bag, providing perineal care around an indwelling urinary catheter, and reapplying sequential compression devices can be performed safely by unlicensed assistive personnel. Assessing the patency of a wound drain is the responsibility of the registered nurse, and disgruntled visitors should be escorted off the unit by security.

Question 2

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.

Accepted Answer

11ecbb05_cb96_7b22_b433_33715df08818_MD0009_00 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 B and E). 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 A) Monitoring current objective pain level (numeric scale) (Option D) (Option C) 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.

Question 3

The postpartum nurse receives report on 4 mother-baby couplets. Which tasks can be delegated to unlicensed assistive personnel? Select all that apply.

Accepted Answer

11ecbb05_cb96_f053_b433_8bc392b203cb_MD0009_00 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 B) 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 D) 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.

Question 4

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?

Accepted Answer

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 D). 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 A) 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 B) 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 C) 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.

Question 5

Which client assignment is most appropriate for the nurse on an orthopedic unit to assign to a float nurse from a general medical unit?

Accepted Answer

The client with the cast applied 24-hours ago is stable and is the most appropriate assignment for the float nurse. This client requires the nurse to perform basic pain, peripheral vascular (eg, color, temperature, capillary refill, peripheral pulses, edema), and peripheral neurologic (eg, sensation and motor function) assessments, which should be familiar to a nurse who works on a general medical unit. (Option A) This client is unstable and requires frequent assessments to identify signs and symptoms of infection and changes in neurovascular status (for compartment syndrome). Pin care is needed as well. (Option B) The client waiting to be discharged requires extensive discharge teaching about using a continuous passive motion device, weight-bearing restrictions and assistive devices, anticoagulation prophylaxis, and rehabilitation. (Option C) The client scheduled for an amputation requires preoperative teaching and psychological support specific to this type of surgery (eg, phantom pain, change in body image). Therefore, this client should be assigned to a nurse who is familiar with preparing clients for orthopedic surgery. Educational objective: The nurse on the orthopedic unit, who is giving client assignments to a float nurse, must consider how to best meet the needs of the clients safely. The most appropriate assignment is a stable client, who requires basic pain, peripheral, and neurovascular assessments, which should be familiar to a float nurse from a general medical unit.

Question 6

The nurse is making assignments for the next shift.  Which client should the nurse assign to the new nurse coming out of orientation?

Accepted Answer

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 A) 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 B) 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 C) 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. Educational objective: The client with a complex illness or one who is unstable (uncontrolled diabetes with hyperglycemia) should be assigned to a more experienced nurse. In addition, tasks requiring advanced skills (ultrafiltration, IV administration of high-risk medications) should be assigned to nurses who have had time to refine their basic skills and have acquired more advanced assessment expertise.

Question 7

While caring for a client in skeletal traction, which tasks can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) to help prevent immobility hazards? Select all that apply.

Accepted Answer

The UAP has the skills and knowledge to perform standard procedures to prevent immobility hazards for a client in traction (eg, pneumonia, pressure ulcers, foot drop, thromboembolism). When providing care for a stable client, the RN can safely delegate these tasks to the UAP: Assist with active and passive ROM exercises after the client has been taught how to perform them by the RN or physical therapist (Option A) Notify the RN of client reports of pain, tingling, or decreased sensation in the affected extremity Remind the client to use the incentive spirometer after the client has been taught proper use by the RN or respiratory therapist (Option D) Maintain proper use of pneumatic compression devices (Option E) Remind the client to move frequently using the overhead trapeze (Option B) The UAP changes the linens from the top to the bottom of the bed with assistance; clients are instructed to lift themselves using the overhead trapeze. This approach maintains immobilization of the injured extremity. Logrolling the client will require multiple staff members, including one person to stabilize weights. (Option C) The RN is responsible for peripheral circulation, neurovascular, and skin assessments. Educational objective: To prevent immobility hazards for a client in skeletal traction, the RN can delegate the following tasks to the UAP: Assist with active and passive ROM exercises Notify the RN of client reports of pain, tingling, or decreased sensation in the affected extremity Remind the client to use the incentive spirometer Maintain proper use of pneumatic compression devices

Question 8

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.

Accepted Answer

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 A) Assisting with feeding Reporting changes in ability to eat or difficulty swallowing (Option E) Reporting changes in behavior Placing bed alarms to reduce risk of falls (Option D) (Option B) 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 C) 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.

Question 9

Which client is most appropriate for the charge nurse in the postpartum unit to assign to the float nurse from the intensive care unit?

Accepted Answer

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 A) Mastitis is a very painful infection. A postpartum nurse would be most familiar with the comfort measures associated with mastitis. (Option B) 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 C) Psychosocial adjustment after giving birth can be complex. An experienced postpartum nurse would be trained to assess for signs of adjustment issues. Educational objective: 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.

Question 10

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.

Accepted Answer

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 E), 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 C) to prevent blood from pooling and discoloring the face. Place dentures in the client's mouth before rigor mortis sets in (Option B) 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 D). (Option A) 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. Educational objective: Postmortem care can be delegated to unlicensed assistive personnel at the nurse's discretion (5 rights of delegation). It includes client preparation (eg, hygiene, positioning) and transportation of the body to the appropriate facility.

Question 11

A pediatric nurse is floated to an adult medical surgical unit. Which client assignment would be most appropriate for the pediatric nurse?

Accepted Answer

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 A) Alcohol withdrawal is predominantly a disease of adults. A pediatric nurse would have little experience managing clients with delirium tremens. (Option B) 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 D) 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.

Question 12

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.

Accepted Answer

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 E). UAP can also take vital signs before the transfusion begins and any time after the first 15 minutes of infusion (Options B and C). (Option A) Only nurses are able to verify blood product and client identification for blood transfusion procedures. (Option D) 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. Educational objective: After the registered nurse has initiated and monitored the client for the first 15 minutes of a blood transfusion, measurement of vital signs may be delegated to unlicensed assistive personnel, who may also obtain the blood product from the blood bank.

Question 13

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?

Accepted Answer

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 B). (Option A) 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 C) 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 D) Unstable angina (angina at rest) is a medical emergency that requires specialist-level monitoring and intervention. Educational objective: Assignments for float nurses should be made based on what is within the knowledge and skill of the generalist nurse. A float nurse should be able to administer oral medication and monitor vital signs, whereas myocardial infarction, pacemaker malfunction, and unstable angina should be assigned to an experienced cardiac nurse.

Question 14

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.

Accepted Answer

11ecbb05_cb94_5840_b433_ef342601bfcd_MD0009_00 It is within the unlicensed assistive personnel (UAP) scope of practice to document output from a urinary collection bag (Option A). The UAP can assist the nurse during a procedure by helping to position a client or holding part of the client's body (Option B). The UAP may also perform routine tasks, such as securing a catheter to the client's thigh with an anchor device (Option E). (Option C) 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 D) 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.

Question 15

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.

Accepted Answer

11ecbb05_cb91_720f_b433_d993d5f22ea6_MD0009_00 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 D). 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 A). If this client were experiencing new-onset, unexplained pain requiring intravenous analgesic administration, the client would need assessment by the RN. (Option B) 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 C and E) 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. Educational objective: LPNs may safely perform sterile procedures and routine medication administration. The RN is responsible for discharge planning and performing comprehensive clinical assessments. The nurse should also consider appropriate use of resources when making assignments or delegating tasks.

Question 16

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.

Accepted Answer

11ecbb05_cb96_5411_b433_7b879e014aef_MD0009_00 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 C and F). (Options A and D) 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 B and E) 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. Educational objective: The registered nurse (RN) is responsible for the client's initial assessment, plan of care development, evaluation, and initial teaching. The RN can delegate most medication administration, client monitoring, education reinforcement, and routine procedures to the licensed practical nurse.

Question 17

The nurse is caring for a mechanically ventilated client with a tracheostomy tube in the intensive care unit. What client care tasks can the nurse safely delegate to the unlicensed assistive personnel? Select all that apply.

Accepted Answer

Clients requiring mechanical ventilation receive care from many members of the health care team. Nurses must often delegate tasks to ensure that care is provided in a timely manner. When delegating, nurses must consider the stability of the client and the experience level of unlicensed assistive personnel (UAP). In accordance with the five rights of delegation, nurses may delegate the following client care tasks to the UAP: Performing routine oral care, which will not affect medical stability in a client with a tracheostomy tube (Option A) Measuring and obtaining vital signs (Option D) Testing blood glucose (per hospital policy) Performing personal hygiene and skin care (eg, bathing) Performing passive and/or active range-of-motion exercises (Option E) Measuring output (eg, urinary, drainage) (Option B) The tracheostomy is a surgically created airway with a high risk of infection. Only licensed individuals (eg, registered nurse, licensed practical nurse) should perform tracheostomy care. (Option C) Although an elevated head of bed (HOB) is necessary to prevent ventilator-acquired pneumonia and improve chest expansion, teaching is not within the scope of the UAP and should be performed only by nurses. However, after nurses provide teaching, the UAP may remind the family to keep the HOB elevated. Educational objective: When caring for a ventilated client, nurses may consider delegating the following tasks to unlicensed assistive personnel: vital sign measurement, oral care, personal hygiene, blood glucose testing, passive or active range-of-motion exercises, and measurement of urine and drainage output.

Question 18

The registered nurse (RN) is planning care to prevent venous thromboembolism in several clients. Which tasks can the RN delegate to the licensed practical nurse? Select all that apply.

Accepted Answer

When caring for a client at risk for venous thromboembolism (VTE), the registered nurse (RN) is responsible for assessing the client, including risk factors present, current medications and supplements that affect coagulation (eg, ginger, gingko biloba), and development of complications (eg, pulmonary embolism). The RN must also develop and implement the plan of care, provide client teaching, and evaluate the outcome of interventions. The RN may delegate care to licensed practical nurses (LPNs) and unlicensed assistive personnel using the five rights of delegation. It is within the scope of practice of the LPN to administer most anticoagulant medications and measure and apply compression devices (Options A, B, and D). (Option C) The LPN can collect and report data (eg, vital signs, results from complete blood count and coagulation studies), but analysis and evaluation of the data require the RN's expertise. (Option E) The RN must provide initial education about VTE prevention (eg, medications, preventive measures, bleeding precautions). The LPN may then reinforce teaching to clients as necessary. Educational objective: The registered nurse (RN) is responsible for assessing the client at risk for venous thromboembolism, developing and implementing the plan of care, teaching, and evaluating interventions. The RN may delegate anticoagulant administration, measurement and application of compression devices, and teaching reinforcement to the licensed practical nurse.

Question 19

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)?

Accepted Answer

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 A) 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 C) Total thyroidectomy can be complicated by bleeding (throat compression) or hypocalcemia (if parathyroids were removed inadvertently). Care in these clients is complex. (Option D) 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. Educational objective: Care of stable clients with expected outcomes should be delegated to the LPN. The RN cannot delegate client teaching or care of those who will require ongoing assessment and clinical judgment.

Question 20

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.

Accepted Answer

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 A, D, and E). Assurance of appropriateness and completion of delegated tasks remain the duty of the nurse. (Options B and C) 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. Educational objective: 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.

Exam 5: Leadership & Management

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.

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.

The postpartum nurse receives report on 4 mother-baby couplets. Which tasks can be delegated to unlicensed assistive personnel? Select all that apply.

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?

Which client assignment is most appropriate for the nurse on an orthopedic unit to assign to a float nurse from a general medical unit?

The nurse is making assignments for the next shift. Which client should the nurse assign to the new nurse coming out of orientation?

While caring for a client in skeletal traction, which tasks can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) to help prevent immobility hazards? Select all that apply.

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.

Which client is most appropriate for the charge nurse in the postpartum unit to assign to the float nurse from the intensive care unit?

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.

A pediatric nurse is floated to an adult medical surgical unit. Which client assignment would be most appropriate for the pediatric nurse?

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.

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?

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.

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.

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.

The nurse is caring for a mechanically ventilated client with a tracheostomy tube in the intensive care unit. What client care tasks can the nurse safely delegate to the unlicensed assistive personnel? Select all that apply.

The registered nurse (RN) is planning care to prevent venous thromboembolism in several clients. Which tasks can the RN delegate to the licensed practical nurse? Select all that apply.

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) ?

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.