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Difficulty: HardAssignment, Delegation and Supervision

A registered nurse (RN) on a medical-surgical unit is reviewing the care needs of four clients to determine appropriate task delegation. Which task is most appropriate for the RN to delegate to the unlicensed assistive personnel (UAP)?

  1. A
    Evaluating the respiratory effort and recording the oxygen saturation of a client who is being weaned from a continuous positive airway pressure (CPAP) machine.
  2. Totaling and recording the shift intake and output for a client with heart failure who is receiving continuous intravenous diuretics.Answer
  3. C
    Obtaining the initial admission vital signs and documenting the reported pain level for a client transferring from the emergency department with acute chest pain.
  4. D
    Feeding a client who was admitted two hours ago with a suspected stroke and is currently exhibiting drooling and a weak cough.

Answer

Totaling and recording the shift intake and output for a client with heart failure who is receiving continuous intravenous diuretics.
The unlicensed assistive personnel (UAP) may perform standard, routine tasks such as measuring and recording intake and output, even for clients receiving complex treatments like intravenous diuretics. The registered nurse (RN) retains the responsibility of interpreting the output data and evaluating the effectiveness of the diuretic therapy.

Step-by-Step Solution

1
Analyze the scope of practice for unlicensed assistive personnel (UAP).
UAPs can perform routine, standard, and unchanging procedures such as obtaining vital signs on stable clients, ambulation, feeding (if no swallowing risks), and measuring intake and output.
To identify which tasks fall within the permissible delegation parameters according to the National Council of State Boards of Nursing (NCSBN).
2
Evaluate the clinical stability and complexity of each client vignette.
The client with acute stroke and dysphagia, the client weaning from CPAP, and the new admission with acute chest pain are all unstable or require initial nursing assessment.
Delegation must adhere to the 'Right Circumstance' and 'Right Person' principles, meaning unstable clients or those requiring acute clinical judgment require direct RN care.
3
Select the task that requires data collection without nursing judgment.
Measuring and recording intake and output is a routine measurement task that does not require clinical judgment, making it safe to delegate even if the client is receiving IV diuretics.
The RN is responsible for the evaluation of the I&O data to determine the effectiveness of the diuretics, but the mechanical act of measuring and recording is delegable.

Key Concept

Delegation requires adherence to the Five Rights (Right Task, Right Circumstances, Right Person, Right Direction/Communication, Right Supervision). Tasks requiring assessment, clinical judgment, teaching, or evaluation (EAT) cannot be delegated to a UAP.
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Topics

Assignment, Delegation and Supervision

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