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Difficulty: MediumAssignment, Delegation and Supervision

During a busy morning shift on a medical-surgical unit, a staff nurse is collaborating with an unlicensed assistive personnel (UAP) to provide client care. Which of the following clinical tasks are appropriate to delegate to the UAP? Select all that apply.

  1. Measuring and documenting the hourly urine volume from an indwelling Foley catheter for a client with chronic kidney disease.Answer
  2. Providing oral hygiene and repositioning a client who is comatose following a stroke.Answer
  3. Helping a stable client transfer from the bed to a bedside chair using a mechanical lift.Answer
  4. D
    Determining the cause of newly reported abdominal pain in a client who is two days postoperative.
  5. E
    Demonstrating the correct technique for subcutaneous insulin self-injection to a newly diagnosed diabetic client.
  6. F
    Obtaining a comprehensive set of vital signs on a client experiencing active chest pain and diaphoresis.

Answer

The correct tasks to delegate include measuring and documenting urine volume, providing oral hygiene and repositioning for the comatose client, and transferring the stable client using a mechanical lift.
The correct activities fall within the standard scope of practice for a UAP. They are routine, have predictable outcomes, and do not require nursing judgment. These include measuring fluid output, assisting with routine activities of daily living (ADLs) such as oral hygiene and repositioning, and assisting stable clients with transfers.

Step-by-Step Solution

1
Analyze the role and scope of practice of the Unlicensed Assistive Personnel (UAP).
Determine that UAPs can perform standard, unchanging, and routine procedures (e.g., vital signs on stable clients, ADLs, I&O, ambulation).
Delegation must follow the Five Rights, ensuring the task matches the delegatee's competence.
2
Evaluate each option against the 'EAT' acronym (Evaluate, Assess, Teach), which are tasks reserved exclusively for the RN.
Identify that determining the cause of pain is an assessment/clinical judgment, and demonstrating insulin injection is teaching.
These tasks violate the rules of safe delegation if assigned to a UAP.
3
Assess the stability of the clients described in the remaining options.
Identify that the client with active chest pain and diaphoresis is acutely unstable.
Tasks for unstable clients or those experiencing acute changes in condition should not be delegated to UAPs, as the RN is required for immediate and continuous assessment.

Key Concept

Delegation to Unlicensed Assistive Personnel (UAP)
Estimated Time:1m 30s
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Topics

Assignment, Delegation and Supervision

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