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Difficulty: HardAssignment, Delegation and Supervision

Midway through a shift on a cardiovascular step-down unit, a registered nurse must reallocate tasks due to a sudden influx of admissions. The nurse is supported by an unlicensed assistive personnel (UAP). Which client care activity is most appropriate to assign to the UAP?

  1. Assisting with the oral feeding of a client who experienced an uncomplicated myocardial infarction three days ago and requires activity pacing.Answer
  2. B
    Ambulating a client to the bathroom who just activated the call light to report new, crushing substernal chest pain radiating to the jaw.
  3. C
    Elevating the head of the bed to 60 degrees for a client preparing to eat lunch, two hours following a coronary angiogram via the right femoral artery.
  4. D
    Palpating and documenting the quality of bilateral pedal pulses for a client recovering from a recent femoral-popliteal bypass graft.

Answer

The most appropriate task to delegate is assisting with the oral feeding of the stable client who is three days post-myocardial infarction.
The correct answer is assigning the UAP to assist with feeding the client who is three days post-myocardial infarction. This client is clinically stable, and feeding is a routine activity of daily living (ADL) that does not require nursing assessment, clinical judgment, or teaching. This aligns strictly with the National Council of State Boards of Nursing (NCSBN) delegation guidelines.

Step-by-Step Solution

1
Analyze the UAP scope of practice against the Five Rights of Delegation.
UAPs can perform routine, standard, and unchanging tasks for stable clients, such as feeding, bathing, and taking vital signs.
The RN must retain responsibility for all assessments, clinical judgments, teaching, and evaluation.
2
Evaluate the clinical stability and required interventions for each client in the options.
The client with new chest pain is unstable. The post-angiogram client has specific physiological positioning restrictions. The post-bypass client requires specialized vascular assessment.
Delegation must match the client's acuity and safety needs with the delegatee's competence and legal scope.
3
Identify the safe, routine task that does not require nursing judgment.
Feeding a stable client who requires activity pacing is a standard ADL and does not involve nursing assessment.
This action meets the criteria for the right task, right circumstance, and right person.

Key Concept

Delegation of tasks to a UAP requires ensuring the client is stable and that the task involves standard, routine procedures without the need for clinical judgment or nursing assessment.
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Topics

Assignment, Delegation and Supervision

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