The nurse is delegating supportive care to unlicensed assistive personnel (UAP) for several clients on a medical–surgical unit. Which statement made by the UAP warrants the need for more information?
1. "I can untie the restraint when giving the client a bath."
2. "I will make sure to tie the restraint in a slip-knot."
3. "I will inform you of any changes to the skin."
4. "I will assist the client with hygiene."
1
Rationale 1: The UAP should only untie the restraint while giving a bath if the client is no longer in danger of pulling out lines or becoming combative with staff. This statement indicates the need for the nurse to ask more questions to the UAP.
Rationale 2: The UAP should tie the restraint in a slip-knot.
Rationale 3: The UAP should inform the nurse of any changes to the skin.
Rationale 4: The UAP should assist the client with hygiene.
Global Rationale: The UAP should only untie the restraint while giving a bath if the client is no longer in danger of pulling out lines or becoming combative with staff. This statement indicates the need for the nurse to ask more questions to the UAP. All the other statements indicate an appropriate understanding by the UAP.
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