Which assessment skills could the nurse safely delegate to the unlicensed assistive personnel (UAP)?
1. Assessment of abdomen
2. Collection of nursing history
3. Assessment of client's allergies
4. Measurement of vital signs
Correct Answer: 4
The nurse could safely ask the UAP to measure the client's vital signs. Assessment of the client's abdomen, collection of a nursing history, and assessment of the client's allergies cannot be delegated to the UAP, because they require advanced nursing education.
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The nurse has assessed a patient's body mass index (BMI) to be 19.6 . This assessment of weight versus height indicates that this patient's weight category is in which category?
a. Low health risk b. Overweight c. Obese d. Morbidly obese
A home health care nurse is visiting a patient after a total hip replacement. What should the nurse include when teaching the patient how to protect the new joint?
a. Put an extension on the toilet seat. b. Keep the legs crossed when at rest. c. Frequently change positions from side to side. d. Slowly pull the knee to the chest twice a day to stretch the hip abductors.
You are the nurse working with a client who complains of not sleeping well, waking up several times during the night, and not feeling rested in the morning. You will likely write a nursing diagnosis of:
a. Sleep-Pattern Disturbance b. Intermittent Sleep Pattern c. Restless Sleep Pattern d. Impoverished Sleep Pattern
The nurse clarifies that the difference between a myelomeningocele and a meningocele is that the cyst of a myelomeningocele contains:
a. Membranes and CSF b. Membranes only c. Membranes, CSF, and the spinal cord d. CSF only