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Difficulty: MediumAssignment, Delegation and Supervision

A registered nurse (RN) and an unlicensed assistive personnel (UAP) are providing collaborative care for a group of clients on a heart failure unit. Which of the following tasks are appropriate for the RN to delegate to the UAP? (Select all that apply.)

  1. Measuring and documenting the hourly urine output for a client receiving a continuous furosemide infusionAnswer
  2. B
    Evaluating the pedal pulses and capillary refill of a client wearing bilateral sequential compression devices
  3. C
    Providing education to a client regarding foods to avoid on a strict sodium-restricted diet
  4. Obtaining the morning standing weight for a client admitted with fluid volume overloadAnswer
  5. E
    Auscultating bilateral lung bases for a client who recently reported an increase in shortness of breath
  6. Assisting a clinically stable client with ambulation to the restroomAnswer

Answer

The appropriate tasks to delegate include measuring and documenting urine output, obtaining a morning standing weight, and assisting a stable client with ambulation.
The UAP is trained to assist with routine activities of daily living and collect basic, predictable data. Measuring urine output, obtaining a routine daily weight, and assisting a clinically stable client with ambulation are standard procedures that do not require independent nursing judgment, assessment, or evaluation. Therefore, they are safe and appropriate tasks to delegate.

Step-by-Step Solution

1
Identify the role and scope of practice of the unlicensed assistive personnel (UAP).
The UAP can perform standard, unchanging procedures and assist with activities of daily living (ADLs) for stable clients.
Delegation must adhere to the scope of practice and the Five Rights of Delegation.
2
Evaluate each task for elements of EAT (Evaluation, Assessment, Teaching).
Evaluating pulses, providing dietary education, and auscultating lung sounds involve elements of EAT.
Tasks requiring nursing judgment, clinical assessment, or client education must be performed by the registered nurse.
3
Select the tasks that do not involve EAT and are routine care measures.
Measuring urine output, obtaining a daily weight, and assisting with ambulation are routine tasks without EAT elements.
These tasks have predictable outcomes and do not require independent nursing judgment.

Key Concept

The registered nurse (RN) must not delegate tasks involving Evaluation, Assessment, or Teaching (EAT) to unlicensed assistive personnel (UAP). Routine tasks and ADLs for stable clients are appropriate to delegate.
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Assignment, Delegation and Supervision

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