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    Hesi rn exit proctored exam
    Select All That Apply

    A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

    Explanation & Rationale

    A. Determine if the client needs to have a gait belt applied: Deciding on the need for a gait belt requires nursing judgment and should be assessed by the nurse, not delegated to the UAP. B. Offer to assist the client to void prior to walking in the hall: Voiding before ambulation helps prevent urgency, falls, and discomfort during the walk and is an appropriate task to delegate to a UAP. C. Instruct the client about signs of orthostatic hypotension: Teaching is a nursing responsibility and should not be delegated to the UAP; the nurse should explain these signs to the client. D. Report the onset of any dizziness or light headedness: UAPs should be instructed to monitor and report signs of distress during ambulation, such as dizziness, which could indicate orthostatic hypotension or fatigue. E. Measure the client's vital signs before the client walks: Checking and reporting vital signs before activity is within the UAP’s scope and helps ensure the client's readiness for walking.

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