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    Hesi rn compass 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

    Choice A rationale: Emptying the bladder before physical activity increases client comfort and prevents urgency or incontinence during ambulation. This also reduces the risk of falls associated with rushing to a bathroom. Choice B rationale: Patient education and clinical instruction regarding medical conditions are professional nursing responsibilities. The UAP's scope is limited to assisting with tasks and reporting observations, not providing formal teaching. Choice C rationale: Baseline vital signs are necessary to assess the client's physiological readiness for activity. The UAP can be delegated to collect this data so the nurse can determine if ambulation is safe. Choice D rationale: UAPs must be instructed on specific subjective or objective signs to monitor and report immediately. Dizziness and light-headedness are critical indicators of activity intolerance or potential syncopal episodes. Choice E rationale: Assessing the need for assistive devices or safety equipment like a gait belt requires clinical judgment. The nurse must perform this assessment rather than delegating the decision to the UAP.

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