A nurse works on an oncology unit and delegates personal hygiene to an unlicensed assistive personnel (UAP). What action by the UAP requires intervention from the nurse?
a. Allowing a very tired client to skip oral hygiene and sleep
b. Assisting clients with washing the perianal area every 12 hours
c. Helping the client use a soft-bristled toothbrush for oral care
d. Reminding the client to rinse the mouth with water or saline
ANS: A
Even though clients may be tired, they still need to participate in hygiene to help prevent infection. The other options are all appropriate.
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The ED triage nurse identifies the client who can have treatment delayed for a few hours as the client with a
a. avulsed (knocked-out) tooth. b. broken finger. c. head injury from a fall. d. large laceration that needs suturing.
Which actions by the nurse show an understanding of what the nurse is accountable for? (Select all that apply.)
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1. Does the patient have gastric ulcer disease? 2. Does the patient have cardiovascular disease? 3. Does the patient have gallbladder disease? 4. Is the patient pregnant or lactating?