When caring for a patient with continuous bladder irrigation ...

[arivle123]

When caring for a patient with continuous bladder irrigation after having transurethral resection of the prostate, which action could the nurse delegate to unlicensed assistive personnel (UAP)?
 
  a. Teach the patient how to perform Kegel exercises.
  b. Report any complaints of pain or spasms to the nurse.
  c. Monitor for increases in bleeding or presence of clots.
  d. Increase the flow rate of the irrigation if clots are noted.

Question 2

When admitting an acutely confused 20-year-old patient with a head injury, which action should the nurse take?
 
  a. Ask family members about the patient's health history.
  b. Ask leading questions to assist in obtaining health data.
  c. Wait until the patient is better oriented to ask questions.
  d. Obtain only the physiologic neurologic assessment data.

[Ashley I]

Answer to Question 1

ANS: B
UAP education and role includes reporting patient concerns to supervising nurses. Patient teaching, assessments for complications, and actions such as bladder irrigation require more education and should be done by licensed nursing staff.

Answer to Question 2

ANS: A
When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the patient's health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data, which could adversely affect decision making about treatment. Asking leading questions may result in inaccurate or incomplete information.