You are the leader of a team providing care for six clients. Your team includes yourself (an RN), an LPN/LVN, and a
newly hired UAP who is undergoing orientation to the unit. The clients are as follows:
• Mr. C, a 68-year-old with unstable angina who needs teaching for a cardiac catheterization scheduled this morning
• Ms. J, a 45-year-old experiencing chest pain scheduled for a graded exercise test later today
• Mr. R, a 75-year-old who had a left-hemisphere stroke 4 days ago
• Ms. S, an 83-year-old with heart disease, a history of myocardial infarction, and mild dementia
• Ms. B, a 93-year-old newly admitted from a long-term care facility, with decreased urine output, altered level of
consciousness, and an elevated temperature of 99.5° F (37.5° C)
• Mr. L, a 59-year-old with mild shortness of breath and chronic emphysema
1. For which clients should you assign the LPN/LVN to perform nursing care tasks, under your supervision?
A. Mr. C
B. Ms. J
C. Mr. R
D. Ms. S
E. Ms. B
F. Mr. L
Ans: 1, 3, 4, 6 It is important to recognize that the RN continues to be accountable for the care of all clients
by this team. Appropriate client assignments for the LPN/LVN include clients whose conditions are stable
and not complex. Ms. J is currently experiencing chest pain, and MS. B is a complex new admission.
The health care provider’s orders for Ms. J, who is currently experiencing chest pain, are as follows:
Place on a telemetry monitor, monitor blood pressure and heart rate, obtain a 12-lead electrocardiogram (ECG) when
the client experiences chest pain, administer nitroglycerin (Nitrostat) 0.6 mg sublingually every 5minutes as needed
for chest pain, administer morphine 2 mg IV push as needed for chest pain
2. Which task should you delegate to the newly-hired UAP?
A. Asking Ms. S memory-testing questions
B. Teaching Ms. J about treadmill exercise testing
C. Performing pulse oximetry for Mr. L
D. Monitoring urine output for Ms. B
Ans: D Assessment and teaching are more appropriate to the educational preparation of licensed nursing
staff. Monitoring and recording intake and output are within the educational scope of the UAP. The UAP
could perform pulse oximetry after undergoing orientation and being taught to use the device.
3. The UAP is delegated the task of measuring morning vital signs for all six clients. What would you instruct
the UAP to report immediately?
A. Oral temperature higher than 102° F (38.9° C)
B. Blood pressure higher than 140/80 mm Hg
C. Heart rate lower than 65 beats/min
D. Respiratory rate lower than 18 breaths/min
Ans: 1 A temperature elevation to 102° F is an indicator of an infectious process. The other criterion
parameters are near normal, and assessment/evaluation would instead be based on abnormalities from each
client’s baseline.
The UAP asks you why it is important to notify someone whenever a client with heart disease reports chest pain. You
tell her chest pain may indicate coronary artery blockage and heart muscle damage that will need treatment.
4. The health care provider’s orders for Mr. R, who had a stroke 4 days ago, include assisting the client with
meals. Which person should be assigned to this task?
A. Physical therapist
B. UAP
C. LPN/LVN
D. Occupational therapist
ANS: 2 Assisting clients with activities of daily living (ADLs) such as feeding are most appropriate to the
scope of practice of the UAP.
The oral temperature of Ms. B, the client newly admitted from a long-term care facility with decreased urine output
and altered level of consciousness, is now 102.6° F (39.2° C) and is diagnosed with a bladder infection.
5. You are working on a nursing care plan for Ms. B. Which nursing intervention is most appropriate to
delegate to the UAP?
A. Checking the client’s level of consciousness every shift
B. Assisting the client with ambulation to the bathroom to urinate
C. Teaching the client, the side effects of antibiotic therapy
D. Administering sulfamethoxazole/trimethoprim (Bactrim) orally every12 hours
ANS: 2 Assisting clients with ADLs is appropriate to the educational preparation and scope of practice of the
UAP. Teaching, assessing, and administering medications fall within the scope of practice for licensed
nurses.
6. The LPN/LVN reports that Ms. S will not leave the chest leads for her cardiac monitor in place and asks if
the client can be restrained. What is your best response?
A. “Yes, this client had a heart attack and we must keep her on the cardiac monitor.”
B. “Yes but be sure to use soft restraints so that the client’s circulation is not compromised.”
C. “No, we must have a physician’s order before we can apply restraints in any situation.”
D. “No but try covering the lead wires with the sheet so that the client does not see them.”
ANS: D Standards of practice for the use of restraints require that nurses attempt alternative strategies
before asking that a client be restrained. A physician’s order is required for continued use of restraints but
can be obtained after the fact if the client’s actions endanger his other well-being.
7. Close to the end of the shift, the LPN/LVN reports that the UAP has not totaled clients’ intake and output
for the past 8 hours. What is your best action?
A. Confront the UAP and instruct her to complete this assignment at once.
B. Delegate this task to the LPN/LVN.
C. Ask the UAP if she needs assistance completing the intake and output records.
D. Notify the nurse manager to include this on the UAP’s evaluation.
Ans: 3 The UAP is new to the unit and may need assistance or instruction regarding the completion of this
assignment
8. The “Five Rights” guide delegation of nursing care tasks. As the team leader, list the Five Rights.
Right task, Right person, Right circumstances, Right direction/communication, Right supervision/evaluation