NURS 310 exam review and study guide

Nurs 310 Exam Review and study guide The nurse should be aware of signs of physical, sexual, and emotional abuse and comply with state or provincial mandatory reporting. Signs of abuse may include: • Shaken baby syndrome (ie, irritability or lethargy, poor feeding, emesis, seizures) • Burns in the shape of household items (eg, iron, spatula), from cigarettes, or from immersion in scalding liquid • Repeated injuries in varied stages of healing (eg, bruises, burns, fractures) (Option 4) • Injuries to genitalia • Lapsed time between the injury and the time when care is sought • Inconsistency between the injury and the caregiver's explanation of the injury (eg, client's developmental age, mechanism of injury) (Options 1, 2, and 3) Toddlers and young children are prone to many accidental injuries (eg, aspiration or poisoning from foreign objects in the mouth, climbs onto and falls from furniture, pulling of objects from the table). The injuries and caregivers' explanations are reasonable for these clients. Prior to discharge, the nurse should instruct caregivers on child safety measures within the home to prevent future injury. Educational objective: The nurse should be aware of signs of physical, sexual, and emotional abuse, including repeated injuries in varied stages of healing, shaken baby syndrome, and injuries to genitalia. Suspicion of abuse necessitates mandatory reporting according to state or provincial laws. Paranoia is the belief that others desire or are attempting to persecute or harm (eg, spy on, cheat, follow, poison) the individual. Clients with paranoid delusions often are suspicious of other people, including health care professionals, and may refuse treatment or aid out of fear of being harmed. Management of paranoia focuses on building trust with and grounding the client in reality. When the client believes food has been poisoned, the nurse can build trust and promote adequate nutrition by offering unopened, individually packaged food (Option 4). Educational objective: Nurses caring for clients who have paranoid delusions must work to build a trusting relationship and ground the client while ensuring basic needs are met (eg, nutritional intake). When clients believe food is poisoned, the nurse should offer unopened, individually packaged food to promote adequate intake without reinforcing delusions. Steps for indwelling urinary catheter insertion for the male client include: • Perform hand hygiene and open sterile catheterization kit (Option 3). • Apply sterile gloves and place sterile fenestrated drape with opening centered over penis (Option 2). • Maintaining sterility of gloves, arrange remaining kit supplies on sterile field. Remove protective covering from catheter, lubricate catheter tip, and pour antiseptic solution over cotton balls or swab sticks. • Firmly grasp penis with nondominant hand, retracting foreskin if present. Nondominant hand is now considered contaminated and remains in this position for duration of procedure (Option 6). • Use dominant (sterile) hand to cleanse in a circular motion from the meatus to the glans with antiseptic solution using cotton balls or swab sticks. Use new cotton ball/swab stick with each swipe (Option 4). • Use dominant hand to pick up catheter and insert it until urine return is visualized in catheter tubing (Option 5). • Advance to bifurcation of catheter tubing. Hold in place and inflate balloon (Option 1). Urine return in catheter tubing may be from urethra and does not indicate that balloon tip is fully inside bladder. Because male urethra varies in length, balloon should not be inflated until catheter is fully advanced. Educational objective: To insert an indwelling urinary catheter in a male client, perform hand hygiene, apply sterile gloves and place sterile fenestrated drape, arrange supplies on sterile field, grasp penis with nondominant hand, cleanse from meatus to glans using dominant hand, insert catheter until urine return is visualized, advance catheter to tubing bifurcation, and inflate balloon. Allowing family to be present during resuscitative efforts and invasive procedures can help the family process and cope with the client's condition, alleviate fears and anxiety, and facilitate the grieving process if the expected outcome is poor. The nurse should permit the client's spouse to enter the room and provide a location to observe (out of the care team's way) and another nurse should explain the treatment measures that are occurring (Option 1). Educational objective: During resuscitative efforts and invasive procedures, the nurse should allow family members to be present if they desire. Allowing family members to be present helps with coping, alleviates fear and anxiety, and facilitates the grieving process in the case of a poor outcome. Central venous catheters (CVCs) are used in the treatment of clients who require long-term IV access or are prescribed hypertonic solutions (eg, total parenteral nutrition) or vesicant medications. CVCs can serve as a portal of entry for bacteria, which increases the risk of developing serious bloodstream infections. Nurses caring for clients with CVCs should report any new or worsening signs of infection (eg, fever, chills, erythema at the CVC site) to the health care provider because central line–related bloodstream infections (CRBSIs) require prompt treatment to prevent possible sepsis. In response to a possible CRBSI, the CVC should be removed as soon as possible to prevent continued exposure to the infection source. Blood cultures should be obtained before initiating antibiotic therapy, as antibiotics may contaminate the sample and prevent identification of the infectious organism (Option 4). Educational objective: When caring for a client with signs of a central line–related bloodstream infection, the nurse should obtain blood cultures and remove the device, if possible, before beginning antibiotic therapy. Other nursing interventions (eg, symptom management, documentation) should be done after initiating treatment of the infection. When making room assignments, it is important to remember that a client with an active or suspected infection should not be paired with a client who has a fresh surgical wound or is immunocompromised. A client having an asthma exacerbation does not have an infection and is not at risk for spreading infection to a client who had recent bowel resection surgery (Option 3). Educational objective: When preparing room assignments, the nurse should not place a client who has a fresh surgical wound or is immunocompromised in a room with a client who has an active or suspected infection. Advance directives outline the client's choices for medical care (eg, cardiopulmonary resuscitation [CPR], mechanical ventilation) ahead of time. This allows the family and care team to follow the client's wishes at the end of life, when the client may be unable to make choices known. Clients can sign a do not resuscitate (DNR) directive instructing that CPR and other life-saving measures be withheld. With an advance directive in place, the client's wishes are followed, even if they conflict with the wishes of loved ones (Option 3). This is different from a medical power of attorney (health care proxy) in which the client designates a person to make decisions on their behalf. Educational objective: Advance directives outline the client's choices for medical care at the end of life, including resuscitation status. Client's wishes for medical care are honored over the wishes of family members. Suicide risk & protective factors Risk factors • Psychiatric disorders, prior suicide attempts • Hopelessness • Never married, divorced, separated • Living alone • Elderly white man • Unemployed or unskilled • Physical illness • Family history of suicide, family discord • Access to firearms • Substance abuse, impulsivity Protective factors • Social support/family connectedness • Pregnancy • Parenthood • Religion & participation in religious activities Clients receiving treatment for depression and suicidal ideation must be carefully monitored for indications of increasing suicidal intent. During a client interview, the nurse should assess: • Access to psychiatric medications • Availability of help during a crisis (eg, counselor, family) • Future goals and plans • Home and work environment risks • Overall affect and level of energy • Possible access to weapons Clients who articulate long-term personal goals and family milestones are less likely to commit suicide (Option 2). Educational objective: Nursing care for clients with suicidal ideation includes assessment of home and work environments, access to psychiatric medications, overall affect, availability of help, access to weapons, and energy level. Clients who articulate long-term personal goals and family milestones are less likely to commit suicide. The nurse is preparing to administer acetaminophen to a 4-year-old client weighing 43 lb. Based on the prescription, what is the volume of medication in milliliters (mL) that the child should receive with each dose? Click on the exhibit button for more information. Record your answer using a whole number. The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to hinder healing? Bone healing depends on multiple factors, including nutrition, adequate circulation, and age. A client with peripheral arterial disease has decreased perfusion to the extremities due to atherosclerotic changes in the arteries. Without adequate perfusion, the bone is not supplied with the oxygen and nutrients required for healing (Option 4). Educational objective: Bone healing after fracture depends on multiple factors, including age, nutritional status, and perfusion. A client with peripheral arterial disease is at risk for impaired bone healing. Based on the nursing assessment progress notes, what is the correct staging of the client's pressure injury? Click on the exhibit button for additional information. Pressure injuries are staged from 1 to 4 to classify the degree of tissue damage and determine the most appropriate and effective wound treatments. • Stage 1: Intact skin with nonblanchable redness • Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis or epidermis; the wound bed is red or pink and may be shiny or dry • Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or bone; tunneling may be present • Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar (scabbing, dead tissue) may be present; undermining and tunneling may be present • Pressure injuries are described as "unstageable" if the base is covered by necrotic tissue or eschar Educational objective: Stage 2 pressure injuries have partial-thickness skin loss (abrasion, blister, or shallow crater). The skin blisters or forms an open sore, and the area around the sore may be red and irritated. A client with type 1 diabetes has prescriptions for NPH insulin and regular insulin. At 7:30 AM, the client's blood glucose level is 322 mg/dL (17.9 mmol/L), and the client's breakfast tray has arrived. What action should the nurse take? Click on the exhibit button for additional information. Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular) and rapid-acting (lispro, aspart) insulins in one syringe (Option 4). Due to the client's blood glucose reading (322 mg/dL [17.9 mmol/L]), 12 units of regular insulin are needed along with the scheduled 25 units of NPH insulin. Prepare the mixed dose: 1. Inject 25 units of air into the NPH insulin vial without inverting the vial or passing the needle into the solution. 2. Inject 12 units of air into the regular insulin vial and withdraw the dose, leaving no air bubbles. 3. Draw 25 units of NPH insulin, totaling 37 units in one syringe. Any overdraw of NPH into the syringe will necessitate wasting the entire quantity. Most long-acting insulins (eg, glargine, detemir) are not suitable for mixing and typically are packaged in prefilled injection pens. Educational objective: NPH insulin and regular insulin may be safely mixed and administered as a single injection. Regular insulin should be drawn into the syringe before intermediate-acting insulin to avoid cross-contaminating multidose vials (mnemonic – RN: Regular before NPH). The pediatric nurse plans a home visit for a 2-year-old who will soon be discharged with home health care. Which condition presents the most concern as a safety hazard in the child's home environment? The safety of the home environment should be assessed prior to discharge of pediatric clients, especially those with illnesses requiring continuing health care services in the home. The nurse can prioritize safety risks according to Maslow's hierarchy of needs. An open wood-burning stove is a fire hazard that may cause physiological damage from smoke inhalation or burns (Option 2). The nurse should investigate the family's access to other utilities and determine whether the stove is the home's only source of heat. Educational objective: A wood-burning stove is a fire, burn, and smoke-inhalation hazard with the potential to cause physiological damage. The nurse should assess all clients' access to utilities and resources. Education on lead-based paint should be provided to those living in homes built before 1978. While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls off the bed and the tube becomes dislodged from the chest wall. What is the nurse's priority action? Chest tubes are inserted into the pleural cavity to facilitate drainage of air (pneumothorax), blood (hemothorax), or other fluids. Chest tubes are sutured in place, but dislodgement can occur. If this happens, a sterile occlusive dressing (eg, petrolatum gauze) must immediately be placed over the insertion site until the health care provider can assess the client and insert a new chest tube. If such dressings are not immediately available, the nurse should cover the insertion site with something clean and occlusive (eg, gloved hand) to prevent air from entering the pleural cavity. Educational objective: Chest tubes are inserted into the pleural cavity to drain air (pneumothorax), blood (hemothorax), or other fluids. If the tube is accidentally dislodged, a sterile occlusive dressing is placed over the site. If such dressings are not immediately available, a clean gloved hand can be placed over the site to prevent air entry into the pleural space. After dressing the site, the nurse should reassess the client and notify the health care provider immediately. The nurse is caring for a client who had an anterior wall myocardial infarction 2 days ago. The telemetry technician notifies the nurse at 8:30 AM that the client is in ventricular trigeminy. What is the nurse's priority intervention? Click the exhibit button for additional information. In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias (eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress, stimulants, fever, and exercise. This client's morning laboratory results show hypokalemia (potassium 3.5 mEq/L [3.5 mmol/L]); therefore, the priority is treatment of the underlying cause of the ectopy by administering the prescribed potassium replacement (Option 1). Health care providers (HCPs) often prescribe electrolyte replacement algorithms to clients at risk for electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless a contraindication exists (eg, serum creatinine 1.5 mg/dL [133 µmol/L], anuric, weight 99.2 lb [45 kg]). Educational objective: Myocardial injury can predispose a client to premature ventricular contractions (PVCs), placing the client at risk for lethal dysrhythmias (eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress, stimulants, fever, and exercise. Treatment of the underlying cause is the priority. A nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first? A client who undergoes percutaneous coronary intervention (PCI) and intracoronary stent placement using the femoralapproach is at increased risk for retroperitoneal hemorrhage. Administration of antithrombotic drugs before, during, and after PCI can exacerbate potentially life-threatening bleeding from the femoral artery. Hypotension, back pain, flank ecchymosis(Grey-Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention/evaluation (eg, notify health care provider, serial CBCs, abdominal CT). (Option 1) During a heart transplant, the donor heart is cut off from the autonomic nervous system (denervated), which alters the heart rate during rest and exercise after the transplant. The transplanted heart is expected to be tachycardic (eg, 90- 110/min). (Option 3) Infective endocarditis is often associated with cardiac valve disease and requires long-term antibiotic therapy (4- 6 weeks). Characteristic manifestations include fever, myalgia, chills, joint pain, anorexia, and petechiae. (Option 4) Some clients notice swelling in the leg used for donor venous graft (interruption of blood flow). Elevating the leg and wearing compression stockings can help decrease symptoms. Educational objective: Percutaneous coronary intervention via the femoral approach places the client at increased risk for retroperitoneal hemorrhage, which is exacerbated by anticoagulants. Back pain, hypotension, flank ecchymosis (Grey-Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention. There has been a major disaster involving a manufacturing plant explosion. The emergency department nurse is sent to triage victims. Which client should the nurse send to the hospital first? During a mass casualty event, the goal of the nurse is to triage rapidly and provide the greatest good for the greatest numberof people. Clients are commonly triaged using a color-coded system and placed into 4 categories. When prioritizing clients for treatment, emergent needs should be managed first, followed by urgent and then nonurgent. The client with an open fractureand impaired distal perfusion (eg, absent distal pulses, capillary refill 3 seconds) has an emergent need for care as limb loss may occur without rapid intervention (Option 3). (Option 1) Nonurgent treatment is appropriate for the client with partial-thickness burns to a small portion of the body (eg, hands). (Option 2) Depending on the size and depth of the laceration, this client would most likely be categorized as nonurgent or urgent. (Option 4) A large, open head wound and a Glasgow Coma Scale score of 3 is indicative of severe neurological trauma. This client has a poor prognosis regardless of treatment (expectant) and would be the lowest priority. Educational objective: During a mass casualty event, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system that establishes them with highest medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (expectant). The nurse is teaching about constipation prevention to a client. Which of the following client statements indicate appropriate understanding of the teaching? Select all that apply. Constipation is a symptom of many disease processes (eg, Parkinson disease, diabetic neuropathy, depression), procedures (eg, abdominal surgery, bowel manipulation), and medications (eg, anticholinergics, diuretics, opioids). Immobility, a low- fiber diet, decreased fluid intake, and irregular bowel habits increase the likelihood of constipation. Educate clients to prevent constipation by: • Encouraging a healthy bowel regimen (eg, avoid delaying defecation if the urge is felt, defecate at the same time dailywhen possible, track bowel movements to identify changes in patterns) (Option 2) • Increasing consumption of fruits and vegetables to reach a daily fiber intake of at least 20 g (unless contraindicated) because fiber softens and increases the bulk of stool, which promotes defecation (Option 4) • Increasing daily exercise levels because activity stimulates peristalsis and promotes defecation (Option 5) • Drinking 2-3 L of noncaffeinated fluids daily (unless contraindicated), which prevents drying and hardening of stool in the colon (Option 1) Clients should avoid caffeinated beverages, which promote diuresis and dehydration and may lead to constipation. (Option 3) Clients should avoid using laxatives and enemas unless prescribed by a health care provider because overuse can cause physical and psychological dependence. Educational objective: Constipation is a symptom of many disease processes, procedures, and medications. To prevent constipation, educate the client to increase daily fiber intake, drink 2-3 L of fluids daily, increase daily activity levels, and initiate a bowel regimen (avoiding delay of defecation, defecating at the same time each day). The nurse receives handoff of care report on four clients. Which client should the nurse assess first? Hallucinations represent a serious safety risk to the client and others because these may compel clients to engage in behaviors or activities that trigger self-injury or violence toward others (eg, command hallucinations). Hallucinations experienced by clients without a psychiatric illness may indicate withdrawal from alcohol or narcotics, which can be life- threatening without prompt intervention. Nurses should promptly assess clients with new or worsening hallucinations (Option 1). (Option 2) Clients undergoing abdominal surgery (eg, exploratory laparoscopy) often have nausea and absent bowel sounds for the first few hours postoperatively due to side effects of anesthetics and decreased peristalsis after bowel manipulation. (Option 3) Clients with diabetes mellitus may develop diabetic neuropathy as a complication of neurovascular damage from inadequate long-term blood glucose management. Feeling "pins and needles" is an uncomfortable but harmless symptom of diabetic neuropathy. (Option 4) Resting tremors are an expected finding with Parkinson disease. Carbidopa/levodopa, a common medication used to manage symptoms of Parkinson disease, can cause a harmless darkening of urine color (eg, brown, black). Educational objective: Clients with new or worsening hallucinations require prompt assessment. Hallucinations increase the risk for injury to self and others and may be a symptom of life-threatening illnesses (eg, alcohol withdrawal). A client with sickle cell crisis reports severe generalized pain. Which intervention is a priority for correcting vasoocclusion? Sickle cell crisis occurs when inadequate oxygenation or hydration exacerbates sickling and causes red blood cells (RBCs) to clump together in the capillaries (vasoocclusion). Vasoocclusion causes severe ischemic pain, hypoxia, and possible organ dysfunction if left untreated. Adequate oxygenation and hydration may reverse the acute sickling response. In the sickled state, RBCs cannot carry enough oxygen from the lungs to the tissues, even with supplemental oxygen. The priority intervention is the administration of IV fluids to reduce blood viscosity and restore perfusion to the areas previously affected by vasoocclusion (Option 1). Only after IV rehydration reverses vasoocclusion can nonsickled RBCs effectively carry supplemental oxygen to the tissues (Option 2). Educational objective: Sickle cell crisis results from vasoocclusion of sickled red blood cells in the microcirculation, resulting in severe ischemic pain. The administration of IV fluids reduces blood viscosity and restores perfusion to the areas previously affected by vasoocclusion. The charge nurse assists a student nurse preparing to apply knee-length compression stockings onto a client with chronic venous insufficiency. Which actions by the student nurse would cause the charge nurse to intervene? Select all that apply. Thromboembolic deterrent stockings (TED hose) are elastic stockings that provide graduated compression to the leg to promote venous return and reduce risk of venous thromboembolism. Correct sizing and application of TED hose are essential to effectively promote venous return. Stockings that are too large will not provide adequate compression, and stockings that are too tight or applied incorrectly may impair perfusion. When applying TED hose, the nurse should: • Select a size of knee-length stockings by measuring length from the heel to the popliteal area and circumference at the widest point of the calf (Option 2). • Ensure stockings are free of folds, rolls, or wrinkles; these may have a tourniquet-like effect, exacerbating venous stasis and impairing perfusion (Options 3 and 5). • Discrete wounds should be covered with occlusive dressings (eg, hydrocolloid) before TED hose application. (Option 1) Stockings should be worn continually and may be removed 1-3 times a day for vascular assessment. It is especially important to wear TED hose when the legs are in a dependent position while sitting or standing, usually during the day. Educational objective: Thromboembolic deterrent stockings (TED hose) promote venous return and reduce the risk of venous thromboembolism. TED hose are worn continually and should be properly sized, free of folds, rolls, or wrinkles. The nurse is caring for a client who has been pronounced brain dead. The client is a registered organ donor. The client's family is voicing concerns about the possibility of disfigurement because they want to have an open casket funeral. How should the nurse respond? Friends and family of deceased clients often have questions about, and may even be suspicious of, the organ donation process, especially during their time of loss and grieving. Organ procurement does not leave obvious evidence on the client's body when the body is dressed. Special precautions and techniques are used by the surgical team and funeral home personnel (eg, morticians) to maintain the integrity and outward appearance of the body (Option 2). Funeral arrangements are not delayed by organ donation and the family will not incur any costs related to procurement. An organ transplant coordinator should be consulted by the nurse to address the family's specific questions Educational objective: A deceased client who is registered as an organ donor does not need familial consent for organ procurement to proceed. Organ donation does not delay or interfere with funeral arrangements or leave obvious evidence on the body; deceased clients can still be displayed according to their wishes, including open casket funeral services. The nurse is preparing to teach a 15-year-old primigravid client at 16 weeks gestation during an initial prenatal visit. Which information would be a priority for the nurse to include? Adolescents have an increased risk for complications during pregnancy (eg, low birth weight, preterm birth, preeclampsia, anemia). They may have a self-focused outlook on life and may not consider the consequences of their actions, which may negatively affect their health and that of the fetus. The primary goal of the first prenatal visit is to establish rapport and emphasize the importance of consistent prenatal care so that complications can be prevented or detected early (Option 3). The nurse also monitors for risky behaviors (eg, substance abuse, unprotected sex), nutritional deficiencies, factors affecting emotional well-being (eg, body image concerns related to pregnancy weight gain), and social risk factors (eg, poverty, poor support system, sexual assault/abuse). Educational objective: Adolescents have an increased risk for complications during pregnancy (eg, low birth weight, preterm birth, preeclampsia, anemia). The primary goal of initial teaching is to establish rapport and emphasize the importance of consistent prenatal care so that complications can be prevented or detected early. Four pediatric clients are brought to the emergency department at the same time. Which client should be seen first? Bruising behind the ear (eg, Battle sign) following head trauma may indicate a basilar skull fracture (Option 3). Because of their close proximity to the brainstem, basilar skull fractures pose a risk of serious intracranial injury, which is the most common cause of traumatic death in children. Other signs include blood behind the tympanic membrane, periorbital hematomas (ie, raccoon eyes), and cerebrospinal fluid leakage from the nose or ears. This client requires cervical spine immobilization, close neurologic monitoring, and support of airway, breathing, and circulation. Educational objective: A client with signs of basilar skull fracture (eg, periorbital hematomas, bruising behind the ear, leakage of cerebrospinal fluid) requires immediate cervical spine immobilization, neurologic assessment, and airway, breathing, and circulation support. The nurses on a medical-surgical unit maintain a shared social media page. Which social media posts written by nurses breach client confidentiality? Select all that apply. Nurses are ethically and legally obligated to prevent breaches of confidentiality when using social media. Nurses should protect client confidentiality and safeguard any protected health information (PHI) learned during care. PHI may include the client's name, diagnosis, history, examination results, or treatment and may be discussed only in a private setting with staff members who are directly involved in the client's care. Educational objective: The nurse is responsible for protecting client confidentiality and preventing inappropriate sharing of protected health information (PHI). Sharing a client's PHI on social media breaches confidentiality, even if the client's name is not identified or sharing is in a private message. A nurse is caring for a client who had a transurethral resection of the prostate and is receiving continuous bladder irrigation by gravity. Which tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply. Continuous bladder irrigation is prescribed following surgical transurethral resection of the prostate and prevents obstruction of urine outflow by removing clotted blood from the bladder. A 3-way catheter is used to continuously infuse solution into the bladder by gravity. The catheter drains urine, irrigant solution, and blood into a collection bag. The registered nurse (RN) should consider the five rights of delegation when delegating to unlicensed assistive personnel (UAP): • Catheter care is a routine, noncomplex task that may be safely delegated to UAP (Option 2). • Any client reports of pain or bladder spasms to UAP should be immediately conveyed to the RN as these symptoms may indicate obstruction (Option 3). • Measuring output is routine data measurement. UAP should report the volume to the RN, who will determine the adequacy of drainage (Option 5).