Question 1

Which of the following tasks is appropriate for the RN to delegate to an experienced UAP (Unlicensed Assistive Personnel)?

Accepted Answer

Answer reason: Take vital signs on a stable post-op patient Taking routine vital signs on a stable client is a predictable, standard task that can be delegated to an experienced UAP, with the RN responsible for interpreting and acting on results. Teaching insulin self-injection requires RN-level patient education. Assessing a surgical wound and evaluating pain response after medication require nursing assessment and clinical judgment and must be done by the RN.
Category reason: This question tests the nurse’s decision-making about which tasks can be assigned to UAP based on stability/predictability and need for assessment, which is the NCLEX Management of Care topic of Delegation.

Question 2

True or False A nurse can delegate medication administration to a nursing assistant.?

Accepted Answer

Answer reason: False Medication administration is generally outside the scope of practice of a nursing assistant/UAP and cannot be delegated by the RN. The RN remains accountable for assessing the patient, clinical judgment, and ensuring safe medication administration according to standards and facility policy. While some jurisdictions allow specially trained personnel to administer limited medications in specific settings, a “nursing assistant” is not typically authorized to give medications.
Category reason: This item tests delegation and scope-of-practice decisions (what tasks an RN may delegate to assistive personnel), which is a Management of Care—Delegation topic in NCLEX.

Question 3

The nurse is providing directions to the unlicensed assistive personnel (UAP) regarding clients' hygiene needs. Which is the priority order in which the UAP should assist the clients? Arrange the actions in the order that they should be performed. All options must be used.?

Accepted Answer

Answer reason: A client who is independent with ADLs (activities of daily living) This is an ordering/delegation question that requires sequencing all four clients, not selecting one option. Because the prompt states “Arrange the actions” and “All options must be used,” there is no single best answer choice to justify. Therefore, a single-answer explanation would violate the required answer-explanation consistency.
Category reason: This item tests nursing delegation and prioritization of UAP assistance with hygiene needs, which falls under Management of Care—Delegation.

Question 4

True or False A nurse can delegate sterile dressing changes to a licensed practical nurse (LPN).?

Accepted Answer

Answer reason: True An LPN/LVN may perform sterile dressing changes on stable clients when this skill is within their education, demonstrated competency, and facility policy/state nurse practice act. The RN remains accountable for the overall plan of care, must ensure the assignment is appropriate for the client’s condition, and must provide needed supervision and evaluation of outcomes. Initial assessments, complex wounds requiring clinical judgment (e.g., unstable patient, new/worsening wound, extensive debridement needs), or patient education about the care plan should be retained by the RN.
Category reason: This item tests the RN’s judgment about assigning a clinical task to an LPN, which is a management-of-care responsibility focused on safe delegation and accountability.

Question 5

If I had to take the NCLEX over again, which category would I spend extra time on?

Accepted Answer

Answer reason: Prioritization and delegation are core NCLEX concepts that determine safe assignment of tasks, effective workload management, and appropriate use of assistive personnel. Mastery of delegation rules directly impacts patient safety and exam success.
Category reason: The primary concept emphasized is delegation—deciding which tasks can be safely assigned to others and understanding scope of practice—making Delegation the correct leaf-level category.

Question 6

A registered nurse (RN) and a licensed practical/vocational nurse (LPN/VN) are caring for a client who is violent and self-discontinued their peripheral vascular access. After initiating physical wrist restraints, which of the following tasks may the RN delegate to the LPN?

Accepted Answer

Answer reason: A. Collect data on the client's skin integrity. LPNs can collect focused assessment data and report findings to the RN, including checking skin condition and circulation under restraints at required intervals. Client teaching about the rationale for restraints and ongoing evaluation of continued necessity involve nursing judgment and are RN responsibilities. Initiating peripheral IV access is not universally within LPN scope and, in many settings, is restricted to RNs, especially in unstable/violent situations where higher-level assessment and safety decisions are needed.
Category reason: This question tests which tasks can be assigned to an LPN after restraints are applied, which is a nursing management/role-scope decision under Delegation.

Question 7

You are the of a health care team that consists of one licensed practical/vocational nurse, one nursing assistant, a nursing student and yourself. To whom is it appropriate to assign complete care for?

Accepted Answer

Answer reason: The question is testing delegation of “complete care” within a typical nursing team. An LVN/LPN can provide comprehensive care for stable clients within their scope, including many assessments and interventions, while the RN retains responsibility for overall assessment, care planning, teaching, and evaluation. A nursing assistant cannot take complete patient care because they are limited to basic ADLs and cannot perform nursing assessment/clinical judgment tasks. A nursing student’s assignments must be supervised and are not typically considered appropriate for independent complete care, and the RN should not automatically take all complete care when a qualified LVN/LPN is available for stable patients.
Category reason: This item asks the nurse to decide which team member should receive a patient assignment based on scope of practice and appropriate delegation, which is an NCLEX Management of Care—Delegation concept.

Question 8

You are delegating to a licensed practical nurse (LPN) to wound care on a patient. The LPN has never performed this type of wound care before. What component of delegation have you neglected?

Accepted Answer

Answer reason: Safe delegation requires verifying that the delegated individual has the knowledge, skill, and prior training to perform the specific task safely. If the LPN has never performed that wound care, the delegating nurse must provide appropriate instruction/supervision or assign the task to someone qualified. Delegating beyond the delegatee’s demonstrated abilities increases risk for patient harm and breaches the “right person/right supervision” principles of delegation.
Category reason: This item tests nursing judgment about assigning tasks to an LPN based on training/skills and ensuring safe delegation practices, which fits Management of Care—Delegation.

Question 9

A nurse on a busy postpartum unit has three patients in the need of attention. A nursing assistant volunteers to recheck vital signs on a hypertensive patient. Which of the following is the best response by the nurse?

Accepted Answer

Answer reason: Obtaining routine vital signs is within the nursing assistant’s typical scope, and this delegation supports safe, efficient care on a busy unit. The nurse retains accountability by ensuring the assistant reports the readings promptly so the nurse can interpret the results and act on abnormal findings, which is essential for a hypertensive postpartum patient. Delegating VS collection is more directly aligned with the assistant’s offer than redirecting to unrelated tasks, while refusing help is unnecessary when the task is appropriate to delegate.
Category reason: This item tests nursing judgment about assigning an appropriate task to unlicensed assistive personnel and ensuring reporting and nurse follow-up, which is a Management of Care delegation decision.

Question 10

Which of the following tasks can the nurse safely delegate to a UAP?

Accepted Answer

Answer reason: UAPs can assist with routine, non-sterile, predictable tasks such as ambulation, provided the client is stable and the RN has already assessed safety and provided directions (e.g., use of gait belt, activity limits). Teaching about incentive spirometry requires patient education and evaluation of understanding, which must be done by an RN/LPN per facility policy. Dressing changes for a pressure injury and pain assessment both require clinical judgment/assessment and are not appropriate for UAP delegation.
Category reason: This item tests the nurse’s judgment about which tasks can be assigned to unlicensed assistive personnel versus those requiring nursing assessment, teaching, or sterile/clinical decision-making, which is Delegation under Management of Care.

Question 11

What is an essential consideration when delegating tasks to an LPN?

Accepted Answer

Answer reason: Safe delegation starts with verifying the activity is permitted for the LPN by the nurse practice act and facility policy, and that the client’s condition is stable enough for an LPN to perform it. Comfort level is not the primary legal/safety determinant; competency matters, but scope is the baseline requirement. Direct supervision is not required for every delegated task and depends on client acuity, task complexity, and LPN competence. Documentation should reflect care delivered and outcomes rather than being completed before the task occurs.
Category reason: This question tests nursing judgment about assigning care to an LPN, which is a core Management of Care topic under Delegation.

Question 12

A nurse is delegating tasks to an assistive personnel (AP). Which task is appropriate to delegate?

Accepted Answer

Answer reason: This is a noninvasive, routine activity of daily living that can be safely performed by assistive personnel when the client is stable and the nurse has assessed fall risk and mobility needs. Sterile dressing changes and IV medication administration require nursing judgment and are outside AP scope due to aseptic technique and medication safety responsibilities. Developing a care plan is a nursing process task requiring assessment and clinical decision-making, which cannot be delegated.
Category reason: This question tests appropriate task delegation based on scope of practice and nursing responsibility, which is categorized under Management of Care—Delegation.

Question 13

A charge nurse delegates wound care to a licensed practical nurse (LPN). Which action ensures safe delegation?

Accepted Answer

Answer reason: B) Provide clear instructions and supervise Safe delegation requires the RN to assess the delegatee’s competence, communicate specific expectations (what to do, when to report, and desired outcomes), and maintain accountability for overall client outcomes. Wound care may be within an LPN’s scope depending on complexity and facility policy, but the RN must ensure appropriate supervision and evaluation. Assuming competence or failing to follow up increases risk for errors and missed complications. Delegating wound care to an unlicensed assistant is inappropriate because it typically requires licensed assessment and clinical judgment.
Category reason: This question centers on a charge nurse’s responsibilities for assigning tasks, ensuring supervision, and maintaining accountability—core elements of nursing delegation within Management of Care.

Question 14

What is an appropriate task to delegate to a nursing support worker?

Accepted Answer

Answer reason: Nursing support workers (unlicensed assistive personnel) can safely perform routine, non-invasive activities of daily living such as hygiene, bathing, toileting, and feeding for stable clients. Medication administration (including IV medications) requires nursing assessment, clinical judgment, and licensure due to high risk and need for monitoring and intervention. Ward rounds and drug rounds involve interdisciplinary decision-making, evaluation, and/or medication safety checks that are RN responsibilities. Delegation should match task complexity and predictability with the support worker’s training and the patient’s stability.
Category reason: This question tests assigning tasks to appropriate staff based on scope of practice and patient safety, which is a core Management of Care concept under Delegation.

Question 15

Scenario: A nurse is delegating care for a post-op patient to a UAP. Q. Which task is appropriate to delegate?

Accepted Answer

Answer reason: UAPs may perform routine, non-sterile, non-assessment tasks for stable patients under RN direction. Ambulation assistance is within UAP scope when the RN has assessed the patient’s readiness, provided instructions, and the activity does not require clinical judgment. Incision assessment and patient teaching require RN-level assessment and education. Sterile dressing changes are typically not delegated to UAP because they require sterile technique and ongoing assessment of the wound.
Category reason: This question tests nursing judgment about assigning tasks based on scope of practice and required assessment/teaching, which is best categorized under Delegation.

Question 16

The five rights of delegation

Accepted Answer

Answer reason: In delegation, these five rights are all required components for safe assignment and accountability. Selecting only one would be incomplete and potentially misleading because the framework is intended to be applied together. Therefore, a single-best-answer cannot be derived from the provided content.

Question 17

You have delegated care of a patient in restraints to a nursing assistant. How often should the nursing assistant inspect skin integrity for this patient?

Accepted Answer

Answer reason: Nursing assistants can perform focused skin and extremity checks within the scope of delegated tasks, reporting any redness, swelling, numbness/tingling, or breakdown to the nurse promptly. A 2-hour interval aligns with common restraint-care standards for releasing/repositioning and reassessing skin integrity to prevent complications. Thirty-minute checks are typically used for safety/behavioral monitoring in some settings, whereas 3–4 hour intervals are too infrequent to reliably prevent tissue injury.

Question 18

You and the LPN/LVN you are working with have just finished assisting in a delivery. Which of the following activities should you delegate to the LPN/LVN?

Accepted Answer

Answer reason: Postpartum perineal hygiene and comfort care are standard tasks that can be performed after the RN confirms the patient is stable and provides needed parameters. By contrast, a newborn head-to-toe assessment and postpartum uterine tone evaluation involve assessment for complications and require RN-level assessment and decision-making. Teaching breastfeeding is initial patient education and must be done by the RN, with reinforcement potentially delegated later as appropriate.

Question 19

A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)?

Accepted Answer

Answer reason: Assisting with mobility and hygiene is within typical UAP scope when the RN has assessed stability and provided any needed safety parameters (e.g., fall risk precautions). Pain relief assessment and documentation are nursing assessment responsibilities requiring evaluation of response to therapy. Adjusting an IV pump rate and evaluating an IV site for complications involve IV therapy management and assessment, which must remain with licensed nursing staff.

Question 20

As the RN responsible for a client in isolation, which can be delegated to the PN?

Accepted Answer

Answer reason: Teaching that reinforces previously provided instructions (e.g., how to follow isolation precautions) is within PN scope when the plan of care is established by the RN. Assessing attitudes and evaluating staff compliance are interpretive and evaluative functions requiring RN-level judgment. A comprehensive environmental risk assessment in an isolation context also requires broader clinical judgment and responsibility for safety planning.

Question 21

Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)?

Accepted Answer

Answer reason: Providing observation/companionship while a stable client carries out a previously taught self-care skill is within UAP scope, with the nurse retaining accountability for overall safety. Wound dressing for a pressure injury involves assessing tissue, drainage, and healing and typically requires nursing skill and decision-making. Monitoring a client’s response implies evaluation of tolerance/pain and potential complications, which is nursing assessment. Ostomy/rectal pouch application and ongoing care require skin assessment and complication prevention, making it inappropriate for UAP in most settings.

Question 22

The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?

Accepted Answer

Answer reason: Performing scheduled capillary blood glucose checks with an Accu-Chek is a commonly trained UAP skill when the nurse provides parameters and follows up on abnormal results. Teaching the client/family and assessing for mental status changes require assessment and clinical interpretation, which must be done by the nurse. Skin assessment (evaluating condition/risks) also involves nursing assessment; while a UAP may report observations, the nurse remains responsible for assessing and interpreting findings.

Question 23

Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)?

Accepted Answer

Answer reason: Observing and recording basic skin findings are standard data-collection activities that can be performed by UAP with direction. In contrast, testing stool for occult blood and urine for glucose involves procedural competency and is typically not assigned to UAP in many settings. Nutrition counseling and evaluating/quantifying changes in mental status require nursing assessment and patient education and therefore must remain with the nurse.

Question 24

A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)?

Accepted Answer

Answer reason: At 2 weeks post-tracheostomy, the stoma is typically more established, so routine site care can be performed per facility policy after RN assessment of stability. Teaching airway clearance is RN-level education, and monitoring for shortness of breath requires ongoing assessment and clinical judgment. Changing tracheostomy ties can risk accidental decannulation and is generally performed by licensed staff or with close nurse involvement depending on policy and patient risk.

Question 25

A confused client has been placed in physical restraints by order of the health care provider. Which task could be assigned to an unlicensed assistive personnel (UAP)?

Accepted Answer

Answer reason: Assisting with hygiene, toileting, feeding, and other ADLs for a restrained client fits within standard UAP scope when the nurse provides direction and remains responsible for overall care. Monitoring restraint safety and circulation checks are safety-critical and require clinical assessment and timely decision-making, so they are not appropriate to delegate as stated. Evaluating comfort needs and documenting mental status/muscle strength are evaluative assessments that require RN-level judgment and documentation standards.

Question 26

Which activity can the RN ask an unlicensed assistive personnel (UAP) to perform?

Accepted Answer

Answer reason: Measuring vital signs is a standard UAP skill and can be assigned with clear parameters for when to report abnormal results. In contrast, taking an admission history requires assessment and interpretation, adjusting tube feeding rates is a regulated task requiring nursing judgment, and monitoring a chemotherapy patient involves evaluation for adverse effects and complications. The RN remains responsible for interpreting the blood pressure reading in the context of postoperative risk and acting on any concerning findings.

Question 27

Which one of these tasks can be safely delegated to a PN?

Accepted Answer

Answer reason: Routine stoma care in a client whose ostomy is functioning well is a standard, procedure-based task that can be performed using established protocols. A newly created ostomy or a recent complicated colostomy increases risk for complications and requires RN-level assessment and evaluation. Teaching ostomy care requires comprehensive education and evaluation of learning, which is an RN responsibility.

Question 28

Which tasks, if delegated by the new charge nurse to a unlicensed assistive personnel (UAP), would require intervention by the nurse manager?

Accepted Answer

Answer reason: Delegation must match the task’s risk level and the personnel’s training; UAP can perform routine, noninvasive care for stable patients, but not care that involves special hazards or requires specialized precautions. A client with internal radiation (brachytherapy seeds) requires strict time–distance–shielding principles and facility-specific radiation safety measures that must be implemented and supervised by licensed staff. Assigning this care to a UAP places the worker and others at avoidable risk due to inadequate training in radiation precautions. In contrast, assisting to the bathroom, emptying a urinary drainage bag, and feeding a toddler with an immobilized arm are typical UAP tasks when the client is stable and the nurse has assessed and provided instructions.

Question 29

The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to?

Accepted Answer

Answer reason: In long-term care, UAPs are commonly trained and authorized to obtain and record vital signs, with the nurse responsible for interpreting results and responding to abnormalities. Delegation follows the “right task/right circumstance” principle: stable clients and expected findings make this appropriate to delegate. A volunteer is not part of the clinical staff and should not perform or document patient care tasks, and using an RN/PN for routine vitals is a less efficient use of licensed nursing resources unless the client is unstable or requires assessment.

Question 30

The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client?

Accepted Answer

Answer reason: Marked decreased responsiveness represents a potential neurologic or systemic emergency (e.g., hypoxia, stroke, medication effect, infection) requiring immediate RN assessment and possible rapid escalation. In contrast, small isolated changes in vital signs (RR +2, HR +10, SBP -8 mmHg) can be within normal variation and are appropriate for the assistant to recheck and report if the client is otherwise stable. A change in level of consciousness is a high-priority, time-sensitive finding that should not be delegated.

Question 31

Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?

Accepted Answer

Answer reason: First-time postoperative ambulation carries a significant risk of orthostatic hypotension and falls, so safety-focused, specific instructions are essential when delegating to a UAP. Allowing the client to dangle at the bedside before standing helps the circulatory system adjust and provides time to assess for dizziness or weakness before weight-bearing. Telling the UAP to manage dizziness with deep breaths is an unsafe response because it does not address hypotension and delays appropriate nursing assessment. Asking for a report of how the client feels after transfer appropriately supports monitoring, but it is less directly preventive than the concrete pre-stand safety step in the correct option.

Question 32

The nurse in the same day surgery unit assigns the unlicensed assistive personnel (UAP) to give a 1000 ml soap solution enema (SSE) to a client scheduled for an abdominal hysterectomy. Which statement by the nurse is most appropriate?

Accepted Answer

Answer reason: Delegation requires the nurse to provide appropriate direction while retaining responsibility for assessment, evaluation, and clinical judgment. Asking the UAP to report the results supports monitoring the client’s response and any potential complications (e.g., inadequate evacuation, intolerance) so the nurse can decide if further action is needed. Directions like giving repeated enemas until clear or specifying a fixed number of enemas involve ongoing evaluation and treatment decisions that should not be independently carried out by UAP. Managing cramping during instillation is a procedural tip, but it does not address the nurse’s responsibility to evaluate outcomes and ensure safe perioperative preparation.

Question 33

A charge nurse working in a long term care facility is making out assignments. Which assignment to an unlicensed assistive personnel (UAP), if made by the nurse, requires intervention by the supervisor?

Accepted Answer

Answer reason: Discharge education for enteral tube feeding involves evaluating the family’s understanding, instructing on technique and complications (e.g., aspiration risk, tube patency, infection), and validating return demonstration, which are RN responsibilities. Assigning this teaching to UAP is inappropriate because it requires clinical knowledge, critical thinking, and accountability for patient/family learning. In contrast, bathing and feeding a stable client on bed rest are basic ADLs that are appropriate for UAP with RN supervision.

Question 34

When walking past a client's room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention?

Accepted Answer

Answer reason: Delegation requires the nurse to ensure tasks are assigned only to personnel who are trained/competent and permitted by policy and scope to perform them, with appropriate supervision. Asking one UAP to do a bedside glucose test because of time pressure reflects an unsafe delegation decision because point-of-care testing is often restricted to trained, competency-validated staff and involves interpreting results and responding to abnormal values. The motivation (“late for lunch”) suggests prioritizing staff convenience over patient safety and proper accountability. The other statements reflect teamwork, reporting a change in condition, or planning routine care and do not inherently indicate an unsafe scope-of-practice issue.

Question 35

The care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)?

Accepted Answer

Answer reason: Delegation to UAP is appropriate for routine, non-sterile, low-risk tasks for stable clients that do not require nursing assessment, teaching, or clinical judgment. This client’s needs commonly include basic hygiene, repositioning, and reporting observations (e.g., drainage amount, odor, skin changes), which UAP can perform while the nurse retains responsibility for wound assessment and treatment decisions. In contrast, a pre-op adrenalectomy client with asthma and a new admission with neurologic symptoms are higher-risk and require focused assessment and monitoring by an RN. A client who is noncompliant requires nursing counseling/education and evaluation of barriers, which cannot be delegated.

Question 36

Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?

Accepted Answer

Answer reason: Serial head circumference in an infant with meningitis is a routine measurement that supports monitoring for increased intracranial pressure and can be safely performed by a PN with RN review of trends. Airborne isolation is not indicated for typical bacterial meningitis (droplet precautions are used for organisms like meningococcus), so adding that would be inappropriate. Passive range of motion and a protective crib top are not priority early interventions in acute meningitis and may pose safety concerns if they increase agitation or do not address neurologic deterioration monitoring.

Question 37

Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP?

Accepted Answer

Answer reason: Obtaining vital signs is a noninvasive, repeatable skill that the RN can supervise, and any abnormal findings can be reported back for RN evaluation. In contrast, assessment after an acute myocardial infarction requires clinical assessment and interpretation, which cannot be delegated to UAP. Discharge planning involves coordination and patient education, requiring licensed nursing oversight rather than assistive personnel.

Question 38

An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?

Accepted Answer

Answer reason: Safe delegation requires the RN to verify the delegatee’s demonstrated competencies and prior experience that match the specific tasks and population being assigned. This question assesses both the types of tasks the UAP routinely performs and whether they have experience with pediatric age groups, which directly informs safe task selection and supervision needs. Asking only about years worked or units floated to is less specific and may not reflect current, relevant skill performance. Comfort level is subjective and does not confirm competence, and reviewing a skills list does not establish that the UAP can safely perform those skills with children in practice.

Question 39

The RN delegates the task of taking vital signs of all the clients on the medical-surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client's blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that client's left arm. Which of these statements is most accurate?

Accepted Answer

Answer reason: The core delegation principle is that the RN retains accountability for the overall outcome of delegated care, including ensuring the task is completed correctly and intervening when it is not. Taking vital signs is an appropriate UAP task, and the RN provided clear written and verbal direction regarding the post-mastectomy restriction, so the error does not automatically mean the delegation decision itself was inappropriate. However, the RN must supervise and evaluate delegated performance, and the presence of the cuff on the restricted arm indicates a failure in the delegated process that ultimately remains under RN accountability. The UAP may be responsible for following instructions, but that responsibility does not remove the RN’s professional accountability for patient safety and follow-up supervision.

Question 40

Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to ambulate a client for the first time after a colon resection?

Accepted Answer

Answer reason: " First-time ambulation after abdominal surgery carries a high risk of orthostatic hypotension and falls, so safety-focused stepwise positioning is the key instruction a UAP can implement reliably. Having the client dangle at the bedside allows assessment for dizziness/weakness and promotes physiologic adjustment before standing. The other options either require clinical assessment/judgment (evaluating pain during ambulation) or provide incomplete/unsafe direction (deep breathing does not address hemodynamic instability, and “as often as the client wishes” lacks parameters and may exceed tolerance early post-op). This instruction is clear, measurable, and directly reduces fall risk during delegated ambulation.

Question 41

A patient in a long-term care facility who has anemia reports chronic fatigue and dizziness with minimal activity. Which nursing activity will the nurse delegate to the unlicensed assistive personnel (UAP)?

Accepted Answer

Answer reason: Orthostatic vital signs are objective measurements that a trained UAP can obtain and report, which is useful given dizziness with minimal activity suggesting possible orthostatic intolerance. In contrast, evaluating response to ADLs and determining independent self-care capacity are assessments requiring RN judgment and care planning. Diet selection to improve strength involves patient education and nutritional counseling, which is also outside UAP scope and must be directed by the nurse (and often dietitian).

Question 42

Which of these tasks related to intravenous therapy is in the scope of responsibilities for a nursing assistant?

Accepted Answer

Answer reason: Observing an IV infusion site and flow for obvious issues (e.g., leakage, swelling, redness, alarms, or empty bag) and notifying the nurse supports patient safety without independently adjusting therapy. Tasks such as preparing IV solutions or initiating/connecting IV feedings involve medication/sterile preparation and clinical judgment, which are outside typical nursing assistant scope. The safest delegated action is surveillance and timely reporting so the RN can assess and intervene.

Question 43

A registered nurse (RN) and a licensed practical/ vocational nurse (LPN/VN) are caring for a client who is violent and self-discontinued their peripheral vascular access. After initiating physical wrist restraints, which of the following tasks may the RN delegate to the LPN?

Accepted Answer

Answer reason: Delegation to an LPN/VN is appropriate for focused, routine data collection and implementation tasks for stable, expected conditions. After restraints are applied, monitoring and documenting skin integrity and circulation at restraint sites is a standard, predictable assessment component that can be gathered by the LPN and reported to the RN. Client teaching about restraints and ongoing determination of continued restraint necessity require RN-level comprehensive assessment, judgment, and evaluation. Initiating a new peripheral IV is not a universally permitted LPN function and, when allowed, typically requires additional certification and institutional policy support, making it a less defensible delegated choice on NCLEX-style questions.

Question 44

The nurse manager reviews tasks delegated to unlicensed assistive personnel (UAP). Which of the following tasks requires follow-up by the nurse manager?

Accepted Answer

Answer reason: Client education and evaluation of learning are RN responsibilities and are not appropriate to delegate to UAP. This task involves teaching/reinforcing self-management skills and requires nursing judgment to assess understanding, correct technique, and readiness to learn. UAP may assist with basic, routine, non-judgmental care such as hygiene, ambulation with assistive devices per plan, and prescribed range-of-motion exercises. Therefore, delegating ostomy-care instruction to UAP indicates improper delegation and warrants follow-up by the nurse manager.

Question 45

A charge nurse is delegating tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). Which task would be appropriate to delegate to the LPN?

Accepted Answer

Answer reason: An initial comprehensive admission assessment requires RN clinical judgment and cannot be delegated. IV push pain medication is commonly restricted to RNs (and may depend on state scope and facility policy), making it a higher-risk medication task. Bathing and oral hygiene are basic care activities appropriate for AP rather than using LPN time for tasks requiring nursing skill.

Question 46

The nurse cares for a client who is stable. Which task is appropriate for the nurse to delegate to the assistive personnel (AP)?

Accepted Answer

Answer reason: Measuring vital signs is a standard AP duty, and the nurse can interpret and respond to the findings. Inserting IV or urinary catheters is an invasive procedure that typically requires licensed nursing skill and assessment of technique and complications. Medication administration requires nursing knowledge of indications, contraindications, and monitoring for adverse effects, so it cannot be delegated to AP.

Question 47

The nurse is caring for a client with low back pain. Which action may the nurse delegate to the nursing assistant?

Accepted Answer

Answer reason: Delegation to a nursing assistant is appropriate for routine, non-invasive tasks that do not require nursing assessment, clinical judgment, or interpretation of findings. Repositioning is a standard comfort and mobility measure that can be performed using established safety techniques, with the nurse providing instructions as needed. The other options involve assessment (pain evaluation, abdominal palpation, and skin assessment), which require RN/LPN scope and critical thinking to identify complications and plan care. If repositioning increases pain or neurologic symptoms, the assistant should report immediately for nursing reassessment.

Question 48

A nurse asks a nursing assistant to help admit an elderly client diagnosed with pneumonia. Delegation by the nurse is considered appropriate when the nursing assistant?

Accepted Answer

Answer reason: Delegation to a nursing assistant is appropriate for routine, noninvasive tasks with predictable outcomes that do not require nursing judgment. Measuring height and weight is a standard data-collection activity that can be performed safely by assistive personnel, with the nurse responsible for interpreting the findings. In contrast, collecting a culture and inserting a feeding tube are invasive procedures that require specific training/authorization and carry higher risk. Assessing lung sounds is an assessment requiring RN clinical judgment and cannot be delegated to unlicensed assistive personnel.

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