A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assess neurologic status with the Glasgow Coma Scale.
b. Check and document oxygen saturation every 1 to 2 hours.
c. Cluster client care to allow periods of uninterrupted rest.
d. Elevate the head of the bed to 45 degrees to prevent aspiration.
e. Position the client supine with the head in a neutral midline position.
ANS: B, E
The UAP can take and document vital signs, including oxygen saturation, and keep the client's head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.
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