04.02 Delegation

✅Obtain vital signs Obtaining vital signs is within the scope of practice of a nursing assistant. ✅Collect urine sample Collecting a urine sample is within the scope of practice of a nursing assistant. Perform an assessment Assessing a client is withing the scope of practice of a registered nurse, but not a nursing assistant. Perform triage Triaging the client is within the scope of the nurse, but not the nursing assistant. Administer medications The nurse must administer all medications. The nursing assistant is not able to do this.

Question 1 of 10 The nurse is caring for a client in the emergency department. The client needs vital signs, a urine sample, triage, an assessment, and pain medication. Which interventions can the nurse delegate to the nursing assistant? Select all that apply. Perform triage Administer medications Perform an assessment Obtain vital signs Collect urine sample

ANSWER D ✅The RN cannot delegate checking the crash cart Checking a crash cart is the responsibility of the licensed nurse, and, like any delegated task, the licensed nurse must consider the five rights of delegation prior to delegating the task. These five rights are: right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. Because checking a crash cart involves extensive auditing, charting of equipment, supplies, and medications, there is not a way to evaluate the performance of another person without going through and re-checking the entire thing. This task is too extensive and detailed to delegate. The RN can delegate checking the crash cart documentation, not the supplies No part of the crash cart check can be delegated to a nursing assistant. The RN can delegate checking supplies but not the medications No part of the crash cart check can be delegated to a nursing assistant The RN can delegate checking the entire crash cart No part of the crash cart check can be delegated to a nursing assistant

Question 10 of 10 The nursing staff on a critical care unit must routinely check the crash cart each shift to ensure that all supplies are in place. The RN wants to delegate the task of checking the crash cart to a nursing assistant who is working with her. Which of the following is true regarding this action? A. The RN can delegate checking the entire crash cart B. The RN can delegate checking the crash cart documentation, not the supplies C. The RN can delegate checking supplies but not the medications D. The RN cannot delegate checking the crash cart

ANSWER A ✅Vital Signs A nursing assistant can complete vital signs, but the other tasks are outside of a nursing assistant's scope of practice. Test taking tip: SATA questions may have only one correct answer option. Titrating oxygen up to 2 liters Oxygen titration is outside the scope of practice of a nursing assistant, because it is considered to be a form of medication. The nursing assistant can switch the client to and from a portable tank, but not titrate the amount of oxygen being received. Blood work Blood work is only within the scope of practice of a nurse. Nitroglycerin administration Medication administration is only within the scope of practice of a nurse. X-Ray The chest XR is performed by an X-ray technologist.

Question 2 of 10 A provider has ordered the following tests for a client with chest pain. Which of these can the nurse delegate to the nursing assistant? Select all that apply. A. Vital Signs B. X-Ray C. Blood work D. Titrating oxygen up to 2 liters E. Nitroglycerin administration

answer B ✅Get a POC glucose on a client The nursing assistant can check a client's glucose, but they cannot get vitals on an unstable client or do assessments. Get vitals on an unstable septic client The client is unstable, this is not an appropriate task for the nursing assistant. The nurse should obtain vitals on this client because it will be a part of the nurse's assessment. Listen to a client's lung sounds after a breathing treatment This is an assessment for the nurse to complete. Make arrangements for a ride home for a client Social work should be utilized to help arrange rides.

Question 3 of 10 After receiving report, the nurse is planning client tasks. Which of the following tasks can be delegated to the nursing assistant? A. Listen to a client's lung sounds after a breathing treatment B. Get a POC glucose on a client C. Get vitals on an unstable septic client D. Make arrangements for a ride home for a client

answer B ✅Checking and measuring the output from the foley In a specialized care setting, unlicensed assistive personnel can provide client care in the form of basic tasks that are not outside of their scope of practice. In this situation, the nurse may only delegate the measurement of urine output from the foley. All other practices of providing education and teaching should be done by the nurse. Teaching the client about how to change the colostomy bag Any tasks that are related to education and instruction are outside the scope of practice of unlicensed assistive personnel and are the responsibility of the registered nurse. Instructing the client about which foods are least likely to cause odor Any tasks that are related to education and instruction are outside the scope of practice of unlicensed assistive personnel and are the responsibility of the registered nurse. Gathering informational materials to give to the client Any tasks that are related to education and instruction are outside the scope of practice of unlicensed assistive personnel and are the responsibility of the registered nurse.

Question 4 of 10 A nurse is working in a busy clinic and must provide teaching to a client about caring for a new colostomy. The nurse has a nurse aide to help with some tasks. Which of the following tasks could the nurse delegate to the unlicensed assistive personnel while working with this client? Teaching the client about how to change the colostomy bag Checking and measuring the output from the foley Instructing the client about which foods are least likely to cause odor Gathering informational materials to give to the client

ANSWER A ✅Checking the rhythm on the fetal monitor and reporting it to the nurse Unlicensed assistive personnel can be good resources for clients. In labor and delivery, an RN has many technical tasks, but a nurse aide can help with many activities that are practical with assisting clients. The nurse can delegate the nursing aide to perform such activities as helping a client's husband, providing a back rub, or giving ice chips, but only the nurse should read the fetal monitor. Giving ice chips to a client in labor This is a perfectly appropriate task to delegate to unlicensed assistive personnel. Providing a back rub to a client having contractions This is a perfectly appropriate task to delegate to unlicensed assistive personnel. Assisting a client's husband with finding the snack machine This is a perfectly appropriate task to delegate to unlicensed assistive personnel.

Question 5 of 10 A nurse works in a labor and delivery unit and has two unlicensed assistive personnel helping with tasks. Which of the following tasks is not appropriate for the nurse to delegate to unlicensed assistive personnel? A. Checking the rhythm on the fetal monitor and reporting it to the nurse B. Giving ice chips to a client in labor C. Providing a back rub to a client having contractions D. Assisting a client's husband with finding the snack machine

ANSWER C ✅ ANNDNDNNNNEmpty a urinary catheter and chart the output A nursing assistant can empty a catheter, and if they empty it they should also chart the output. Review discharge paperwork with the client This is considered education, and must be completed by the nurse. Update the family on the plan of care This is the responsibility of the nurse, not the nursing assistant. Perform a swallow screen Any screening must be completed by a nurse rather than the nursing assistant.

Question 6 of 10 A nursing assistant can perform which of the following tasks when delegated to by the nurse? A. Update the family on the plan of care B. Review discharge paperwork with the client C. Empty a urinary catheter and chart the output D. Perform a swallow screen

ANSWER C ✅Putting clean linens on the client's bed A nurse may need to delegate some tasks for help when caring for the body of a deceased client. Providing post-mortem care involves respectfully cleaning and preparing the body for viewing by family, if they are present. The nurse is responsible for removing invasive lines and tubes, gathering paperwork, and talking to the family, but can delegate some tasks to the nurse aide, such as changing bed linens. Telling the family members about the client's death This is a task that the nurse cannot delegate, because they are outside the scope of practice of unlicensed assistive personnel. Gathering paperwork for the mortuary This is a task that the nurse cannot delegate, because they are outside the scope of practice of unlicensed assistive personnel. Removing tubes from the client's body This is a task that the nurse cannot delegate, because they are outside the scope of practice of unlicensed assistive personnel.

Question 7 of 10 A nurse is providing post-mortem care for a client who died 30 minutes ago. Which of the following components of this care can the nurse delegate to unlicensed assistive personnel? A.Telling the family members about the client's death B. Gathering paperwork for the mortuary C. Putting clean linens on the client's bed D. Removing tubes from the client's body

ANSWER B ✅Turning a bedridden client A nursing assistant can turn a client. Placing a nasogastric tube This invasive intervention is outside of the scope of practice of a nursing assistant. Review discharge paperwork with the client This is considered education and must be completed by the nurse. Perform a swallow screen All screenings must be done by a nurse.

Question 8 of 10 The nurse would be correct in delegating which of the following tasks to a nursing assistant? A. Perform a swallow screen B. Turning a bedridden client C. Review discharge paperwork with the client D. Placing a nasogastric tube

ANSWE A ✅Get a temperature and glucose on a client Nursing assistants are able to check vital signs and get a blood glucose. They cannot do assessments, pass medications, or educate clients and/or family members. Get nutrition information for a newly diagnosed diabetes client This is an assessment, and must be done by the nurse. Administer insulin using the sliding scale Insulin is medication, which must be administered by the nurse. Teach a client how to adjust cooking techniques for a diagnosis of diabetes Education is the responsibility of the nurse, and cannot be delegated to the nursing assistant.

Question 9 of 10 The nurses on a busy unit are all needing help so a nurse assistant is asked to assist them. Which of the following tasks should the nurse assign to the nursing assistant? A. Get a temperature and glucose on a client B. Administer insulin using the sliding scale C. Teach a client how to adjust cooking techniques for a diagnosis of diabetes D. Get nutrition information for a newly diagnosed diabetes client