Practice Question
The nurse plans care for a client with urinary retention. What task(s) should the nurse plan to delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
Answer Choices:
Correct Answer:
Bring the bladder scanner into the client's room.
Rationale:
Bring the bladder scanner into the client’s room
🔷 This task is non-invasive and requires no clinical judgment, making it appropriate to delegate to UAP as part of workflow support.
🔷 Having the UAP promptly bring equipment reduces delays in care and allows the nurse to proceed quickly with the assessment and interpretation steps that only an RN should perform.
🔷 It supports efficiency and teamwork while preserving the RN’s time for tasks that involve assessment, planning, and decision-making.
🔷 The UAP can also ensure the device is plugged in, clean, and ready, reinforcing infection prevention and equipment readiness without crossing into assessment territory.
🔷 Delegating this step aligns with the principle that UAP perform task-oriented, predictable activities that have standardized outcomes.
🔷 The RN retains responsibility for operating the scanner, interpreting bladder volumes, and acting on results, preserving the boundary between data gathering support and nursing judgment.
Routinely assist the client to the bathroom
🔷 Assisting with toileting is an Activity of Daily Living (ADL) that is squarely within the UAP scope, requiring skills but not clinical interpretation.
🔷 Regular assisted toileting supports timed voiding/bladder training, which can reduce retention, promote comfort, and prevent overflow incontinence.
🔷 UAP involvement enhances safety and fall prevention by providing standby help, ensuring proper footwear, and using devices like gait belts when indicated.
🔷 Routine assistance also decreases skin integrity risks (e.g., moisture-associated skin damage) by helping the client void at intervals rather than delaying.
🔷 The UAP can observe and promptly report client changes (dizziness, difficulty initiating stream), while the RN synthesizes that information into the care plan.
🔷 Clear instructions (frequency, use call light, do not leave weak clients unattended) keep the activity predictable and low risk, matching safe delegation criteria.
Measure and record the client’s urine output
🔷 Tracking intake and output (I&O) is an objective data collection task that the UAP can reliably perform and document per facility policy.
🔷 Accurate measurement (using a urinal, hat, or graduated container) and timely recording give the RN essential trend data to evaluate renal perfusion and retention.
🔷 The UAP can also note basic characteristics (amount, time, unusual odor/color) and report variances, while the RN interprets significance (e.g., oliguria, hematuria).
🔷 Delegating I&O supports early identification of declining urine output, enabling the RN to intervene quickly (assessment, provider notification) when thresholds are crossed.
🔷 This task is stable, predictable, and standardized, meeting the criteria for safe delegation without requiring nursing judgment.
🔷 Reinforcing proper technique (avoid contamination, keep urinal level, zero the graduate) maintains accuracy and infection-prevention standards.
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This question is from Examplify W4 NR325 NR330 Exam 1 which contains 25 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Maternal-Child
- Answer Choices: 5