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Difficulty: MediumAssignment, Delegation and Supervision

A client admitted with severe fluid volume overload secondary to acute decompensated heart failure is receiving care from a registered nurse (RN) and an unlicensed assistive personnel (UAP). Which task is most appropriate for the RN to delegate to the UAP?

  1. A
    Checking the client's bilateral lower extremities to determine if the pitting edema has worsened since the previous shift.
  2. B
    Reviewing the purpose of the 1,500 mL daily fluid restriction with the client while providing their breakfast tray.
  3. Obtaining the client's daily weight before breakfast and reporting any increase greater than 2.2 lb (1 kg) directly to the RN.Answer
  4. D
    Observing the client's respiratory effort to identify signs of activity intolerance while assisting with a transfer to the bedside commode.

Answer

Obtaining the client's daily weight before breakfast and reporting any increase greater than 2.2 lb (1 kg) directly to the RN.
The correct answer is obtaining the daily weight. This is a routine, standard task with a predictable outcome. By providing specific, objective parameters (reporting an increase > 1 kg), the RN fulfills the 'right direction and communication' requirement of the Five Rights of Delegation.

Step-by-Step Solution

1
Analyze the client's condition and the respective roles of the RN and UAP.
The client has acute decompensated heart failure. The RN is responsible for the nursing process, including all assessments, clinical judgments, and teaching. The UAP performs routine, standard care tasks.
Safe delegation must strictly adhere to the legal scope of practice and the Five Rights of Delegation.
2
Evaluate each option against the criteria for safe delegation to a UAP.
Checking edema is an assessment. Reviewing a fluid restriction is teaching. Observing for activity intolerance is evaluation/clinical judgment. Obtaining a weight with specific reporting parameters is a standard, routine task.
Identifying tasks that require clinical judgment helps eliminate inappropriate delegations that could compromise client safety.

Key Concept

Delegation of tasks to Unlicensed Assistive Personnel (UAP)
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Topics

Assignment, Delegation and Supervision

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