Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel UAP )?
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Solution(d ); The client is exhibiting severe neurovascular compromise, which indicates a surgical complication and requires notifying the surgeon immediately. 2 >>The HCP writes an order for the client with a fractured right hip to ambulate with a walker four times per day. Which action should the nurse implement? ?
Solution(b ); According to the National Council of State Boards of Nursing (NCSBN), collaboration with interdisciplinary team members is part of the Management of Care. Physical therapy is responsible for management of the client’s ability to move and transfer. 3 >>Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) working on a surgical unit? ?
Solution(b ); The UAP can take vital signs on a newly admitted client. 4 >>The licensed practical nurse (LPN) is working in a surgical rehabilitation unit. Which nursing task would be most appropriate for the LPN to implement? ?
Solution(d ); The LPN’s scope of practice allows routine sterile procedures on the client who is stable, such as clients in a surgical rehabilitation facility. 5 >>The unlicensed assistive personnel (UAP) is changing a full sharps container in the client’s room. Which action should the nurse implement? ?
Solution(c ); The nurse should reward appropriate behavior by the other healthcare members. Verbal praise is always appreciated by anyone. 6 >>The unlicensed assistive personnel (UAP) tells the nurse the client who is 5 hours postoperative for an L-3/L-4 laminectomy is complaining of feeling numbness in both feet. Which intervention should the nurse implement? ?
Solution(c ); The nurse should assess the client whenever receiving any information from another member of the healthcare team. 7 >>The ED nurse is requesting a bed in the intensive care unit (ICU). The ICU charge nurse must request a transfer of one client from the ICU to the surgical unit to make room for the client coming into the ICU from the ED. Which client should the ICU charge nurse request to transfer to the surgical unit? ?
Solution(c ); Although the client is only 1 day postoperative for a total hip replacement, it is an elective procedure, which indicates that the client was stable prior to the surgery. The incision is also dry and intact. Of the four clients, this client is the most stable and should be transferred to the surgical unit. 8 >>A terrible storm causes the electricity to go out in the hospital and the emergency generator lights come on. Which action should the charge nurse implement? ?
Solution(b ); During an electrical failure, the red outlets in the hospital run on the backup generator, and all IV pumps and necessary equipment should be plugged into these outlets. 9 >>The HCP is angry and yelling in the nurse’s station because the client’s laboratory data are not available. Which action should the charge nurse implement first? ?
Solution(b ); This is the charge nurse’s first action because it will diffuse the HCP’s anger. Inappropriate behavior at the nurse’s station should not occur in an area where visitors, clients, or staff will observe the behavior. 10 >>The staff nurse is concerned about possible increasing infection rates among clients with peripherally inserted central catheters (PICCs). The nurse has noticed several clients with problems in the last few months. Which action would be appropriate for the staff nurse to implement first? ?
Solution(b ); Possibly increasing infection rates among clients with PICCs falls within the infection control nurse’s scope of practice, and the infection control nursing staff will have data from all units in the hospital. 11 >>The charge nurse on the 30-bed surgical unit has been told to send one staff member to the medical unit. The surgical unit is full, with multiple clients who require custodial care. Which staff member would be most appropriate to send to the medical unit? ?
Solution(c ); The LPN would be the most appropriate staff to send to the medical unit because the LPN has experience on the unit. His or her expertise is also not required to perform custodial care. 12 >>The nurse educator is discussing fire safety with new employees. List in order of performance the following actions the nurse should teach to ensure the safety of clients and employees in the case of fire on the unit. ?
Solution(b ); R is for rescue. 13 >>The client tells the nurse, “I am having surgery on my right knee.” However, the operative permit is for surgery on the left knee. Which action should the nurse implement first? ?
Solution(b ); According to the Joint Commission, the first intervention is to call a time-out, which stops the surgery until clarification is obtained. 14 >>The older adult client fell and fractured her left femur. The nurse finds the client crying, and she tells the nurse, “I don’t want to go to the nursing home but my son says I have to.” Which response would be most appropriate by the nurse? ?
Solution(d ); According to the NCLEX-RN� test plan, advocacy is part of Management of Care under Safe and Effective Care Environment client needs. Therapeutic communication involves being an advocate in this situation, because sometimes the nurse cannot prevent a perceived “bad” situation from occurring. 15 >>The client is confused and pulling at the IV and indwelling catheter. Which order from the HCP should the nurse clarify concerning restraining the client? ?
Solution(a ); The client cannot be restrained as needed. The nurse must have documentation for the need and an HCP’s specific order that includes reason for restraint and time limited to no more than 24 hours. This HCP order should be clarified. 16 >>The charge nurse on a 20-bed surgical unit has one RN, two licensed practical nurses (LPNs), and two unlicensed assistive personnel (UAPs) for a 12-hour shift. Which task would be an inappropriate delegation of assignments? ?
Solution(b ); The LPN may be allowed administer some IVP medications in some facilities, but the word “all” makes this an inappropriate assignment. Many IVP medications are considered high risk, and only RNs should administer such IVP medications. 17 >>The head nurse is completing the yearly performance evaluation on a nurse. Which data regarding the nurse’s performance should be included in the evaluation? ?
Solution(d ); The nurse’s ability to document client care directly correlates with the nurse’s performance; therefore, these data should be included in the yearly evaluation. 18 >>The nurse is discharging the 72-year-old client who is 5 days postoperative for repair of a fractured hip with comorbid medical conditions. At this time, which referral would be the most appropriate for the nurse to make for this client? ?
Solution(c ); The rehabilitation facility will provide intensive therapy and address the comorbid conditions 24 hours a day. This will assist in the client’s recovery. 19 >>The nurse is caring for clients on a 12-bed intermediate care surgical unit. Which task should the nurse implement first? ?
Solution(b ); The client scheduled for surgery is priority and must be ready when the OR calls; therefore, completing the preoperative checklist is the first task the nurse should implement. The preoperative checklist ensures the client’s safety. 20 >>The nurse is preparing to administer medications to clients on a surgical unit. Which medication should the nurse question administering? ?
Solution(a ); Antiplatelet medication will increase the client’s bleeding time and should be held 5 days prior to surgery; therefore, this medication should be questioned. What does rn Nclex mean? Is the Nclex RN hard? Where can I take the Nclex RN? How much is the Nclex RN? Which tasks would the nurse assign to unlicensed assistive personnel UAP )?the nurse to delegate to the unlicensed assistive personnel (UAP)? 1.. Check the client's skin under the restraints.. Administer the client's antipsychotic medication.. Perform the client's morning hygiene care.. Ambulate the client to the bathroom.. Obtain the client's routine vital signs.. Which tasks are appropriate for the unlicensed assistive personnel?Typical UAP Tasks
Common ADLs include bathing and grooming, feeding, dressing, toileting, ambulating, and continence.
What tasks can a UAP perform?Assisting with personal hygiene: bathing, oral hygiene, nail care, and grooming. Assisting with dressing, repositioning, feeding, and toileting. Some states allow UAP's to administer medications after completing a course or can show they are competent in doing so.
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