Ch 20: Effective Delegation and Supervision

19. A nurse is concerned about the risk of delegating tasks to licensed practical nurses and unlicensed assistive personnel. What is the best way for the nurse to determine competency of an inexperienced delegatee? a. Actually observe the delegatee perform the assigned task. b. Ask the delegatee how many times he/she has performed the task. c. Ask the patient if the care provided was satisfactory. d. Ask other nurses if they feel the delegatee is competent.

A The best way for the nurse to determine the competency of LPNs or UAPs is to observe them perform the task. DIF: Application REF: p. 361

2. An RN recently relocated to another region of the country and immediately assumed the role of charge nurse. When determining the appropriate person to whom to delegate, the RN knows that: a. the role of the LPN/LVN is the same from state to state. b. the LPN/LVN can be taught to perform all the duties of an RN if approved by the employer and if additional on-the-job training is provided. c. he or she must review the state's nurse practice act for LPN/LVNs, because each state defines the role and scope of practice of the LPN/LVN. d. The Joint Commission has certified and established roles for the LPN/LVN.

C The scope of practice of the LPN/LVN varies significantly from state to state; RNs should know the LPN/LVN nurse practice act in the state in which they practice and should understand the legal scope of practice of the LPN/LVN. DIF: Comprehension REF: p. 354

22. A nursing administrator who is considering the feasibility of an all-RN staff reviews the report, Keeping Patients Safe: Transforming the Work Environment of Nurses (2003) and determines that RNs: (select all that apply) a. are more costly and less efficient than LPNs. b. have little or no effect by being proactive but instead are reactive to patient care errors. c. have a positive effect on patient outcomes when managing patient care. d. are effective overseers of patients' overall health condition. e. lack the training to be effective delegators.

C, D RNs are effective at coordinating care that results in improved patient outcomes. RNs are valuable monitors of a patient's health status—a practice that results in improved patient outcomes. DIF: Comprehension REF: p. 353

15. An RN makes the following assignments at the beginning of the shift. Which assignment would be considered high-risk delegation? a. A novice RN is assigned a patient with diabetes mellitus requiring mixing of regular and NPH insulin. b. An LPN is assigned an older adult with pneumonia and who requires dressing changes on a foot wound. c. An unlicensed assistive person is assigned the task of assisting a patient with late stages of Huntington's disease to ambulate a short distance in the hallway. d. A float RN from the oncology unit is assigned a patient with a white blood cell count of 4000 mm3.

C Risk of falling is great in later stages of Huntington's disease due to chorea movements. DIF: Application REF: pp. 359-360

11. An RN delegates to an experienced LPN/LVN the task of administering oral medications to a group of patients. The LPN/LVN accepts the assignment, and the RN knows that the LPN/LVN has had the training and has acquired the skills needed to complete the task. The RN then observes the LPN/LVN recording a patient's medication administration just before entering the patient's room. The priority intervention by the RN is to: a. check the patient's drug packages to ensure that the correct drugs were given. b. stop the LPN/LVN immediately and discuss the possible consequences of his actions in a nonjudgmental manner. c. contact the nurse manager and ask that the LPN/LVN's license be suspended. d. call the pharmacy and ask for replacement medications for the patients.

B The LPN/LVN has the competency but violated one of the rights of medication administration and is practicing unsafe care. The RN's responsibility requires that he or she intervene and identify concerns with the LPN/LVN. DIF: Analysis REF: p. 363

5. A nurse is delegating to the newly hired nursing unlicensed assistive personnel (UAP) the task of assisting with oral hygiene, knowing that this assignment "does not require decisions based on the nursing process." The nurse is correctly using which of the five rights of delegation? a. Supervision b. Communication c. Person d. Circumstance

D Right circumstance involves the delegation of tasks that do not require independent nursing judgments. DIF: Comprehension REF: p. 360

20. Care delivery using the team-based approach is used on a telemetry nursing unit. The team consists of one registered nurse (RN), two licensed practical nurses (LPNs), and one unlicensed assistive personnel (UAP). Staff have been charged to improve quality of care while ensuring cost containment. Which assignments would meet both criteria? a. The RN administers all medications to all patients. b. The LPN performs sterile dressings and IV tubing changes on all central lines. c. The experienced UAP places telemetry electrodes and attaches to cardiac monitor. d. The RN administers an enema to a stable patient who has an order "administer fleet enema PRN when no bowel movement in 2 days."

C The UAP, when properly trained, can place patients on telemetry. This meets quality and cost containment goals because the LPN and RN have higher salaries. DIF: Application REF: pp. 353-354

12. Which statement related to delegation is correct? a. The practice of unlicensed assistive personnel (UAP) is defined in the nurse practice act. b. Nursing practice can be delegated only when the LPN/LVN and UAP have received adequate training. c. Supervision is not required when routine tasks are delegated to a competent individual. d. The RN must be knowledgeable about the laws and regulations that govern nursing practice, as well as those that have no clearly defined parameters, such as for UAP.

D Accountability remains with the RN, and he or she is responsible for knowing what tasks can be delegated and what is defined as nursing practice. DIF: Knowledge REF: p. 354

18. A registered nurse (RN) is assigned as charge nurse for the first time. She knows to consult the state board of nursing to determine scope of practice for licensed practical nurses (LPN) and unlicensed assistive personnel (UAP). She also realizes there are common policies which exist in most state practice acts that include: a. the RN is held accountable for the decision to delegate, but responsibility rests only with the delegatee. b. the RN may only delegate tasks that are not in the scope of practice of the LPN if the delegatee is certain they are competent to perform the task. c. since the LPN is licensed, they practice professional nursing. d. to determine what tasks can be safely delegated, the RN must first assess the patient.

D The stability of the patient must be determined prior to delegation. Even routine tasks such as taking vital signs that are often delegated may need to be performed by the RN when the patient's condition is critical. DIF: Comprehension REF: pp. 354-355, Box 20-1

16. The RN instructs the LPN to "Give an enema to the patient in room 327 who is being discharged but is complaining of being constipated. Then be sure to document on the medication administration record when given." Which of the five rights was missing in this situation? The right of: a. direction and communication. b. task. c. person. d. circumstances.

A The directions were not clear. The RN did not specify which type of enema to give and what outcome to expect. And the RN gave no instructions related to reporting back. DIF: Application REF: p. 360

4. A patient is admitted with hypotension, shortness of breath, flushing, and hives. All levels of staff have been trained to assess vital signs. Given budget restrictions and proper delegation rules, to which care provider would the RN delegate the task of obtaining the initial blood pressure reading? a. RN b. LPN/LVN c. Unlicensed assistive personnel (UAP) d. Use the blood pressure obtained in the ambulance, because it was assessed via electronic monitoring.

A The patient's condition is not stable; therefore, the skills of an RN are required. DIF: Application REF: pp. 357-358, Box 20-3

7. An RN delegates to the unlicensed assistive personnel (UAP) the task of performing blood pressure checks for a group of patients on a nursing unit. The UAP accepts the task and is responsible for: a. delegating the task to another UAP if he or she does not have the time or skill to complete the task. b. keeping the RN informed of any abnormal blood pressure readings. c. calling the physician when the patient's vital signs are not within established parameters. d. informing the dietary department to initiate a low-sodium diet for patients who are hypertensive.

B After accepting the assignment, the UAP is responsible for completing the task and reporting any patient concerns to the RN. DIF: Application REF: p. 354

1. The task of completing and signing the initial assessment on a newly admitted patient who is about to undergo minimally invasive procedures on an outpatient basis can be delegated to: a. the registered nurse (RN). b. the licensed practical/vocational nurse (LPN/LVN). c. unlicensed assistive personnel (UAP). d. all levels of staff, because the information is about the past and cannot change.

A Only the RN can perform and sign the admission assessment, although some components such as monitoring vital signs may be delegated. DIF: Comprehension REF: p. 357

3. Which task is most likely to be considered in a state's practice act as appropriate to delegate to a LPN/LVN if the patient's condition is stable and competence in the task has been established? a. Administer an enema for an elective surgery patient. b. Administer an antiarrhythmic medication IV while interpreting the patient's rhythm on the cardiac monitor. c. Develop a plan of care for a stable patient admitted for observation after a head injury. d. Teach a patient how to instill eye drops for glaucoma.

A The RN who is delegating must consider the following: (1) the delegatee's current workload and the complexity of the task, (2) whether the staff member is familiar with the patient population and with the task to be performed, and (3) whether the RN is able to provide the appropriate level of supervision. The delegation decision-making tree would also support delegation of this task. DIF: Analysis REF: pp. 357-358, Box 20-3

21. Which statement made by an RN regarding delegation indicates the need for additional teaching? (select all that apply) a. Unlicensed assistive personnel (UAP) can assess vital signs during the first 5 minutes for a patient who is receiving a blood transfusion because a reaction at this time is unlikely. b. An LPN/LVN can administer a PPD (tuberculin skin test) if there is no history of a positive PPD. c. When dopamine is ordered continuously, the LPN/LVN can administer dopamine at a low dose for the purpose of increasing renal perfusion. d. UAPs can transfer a patient who is being discharged home from the wheelchair to the bed if they have received training and demonstrated competency. e. Responsibility can be delegated to the UAP, but the delegator retains accountability.

A, B, C The statement "UAPs can assess vital signs during the first 5 minutes for a patient who is receiving a blood transfusion because a reaction at this time is unlikely" indicates the need for further teaching because the patient is at highest risk of a reaction during the first few minutes of a blood transfusion; thus the assessment skills of an RN are required. The statement "an LPN/LVN can administer a PPD (tuberculin skin test) if there is no history of a positive PPD" indicates the need for further teaching because administration of intradermal medication requires the skill of an RN. Dopamine is a vasoactive drug that can have a profound effect on a patient's blood pressure and cardiac output; administration requires the assessment and evaluation skills of an RN. DIF: Analysis REF: pp. 357-358, Box 20-3

23. Which functions can be delegated only to another RN with appropriate experience and training? (select all that apply) a. Assessment of skin integrity on third day of hospitalization b. Evaluation of patient teaching related to turn, cough, and deep breathing exercises c. Nursing judgment related to withholding medication based on vital signs d. RNs do not delegate to other RNs, they delegate only to licensed practical nurses or unlicensed assistive personnel e. Formulation of nursing diagnosis "potential for fall"

A, B, C, E Activities like assessing skin integrity—which include the core of the nursing process and require specialized knowledge, judgment, and/or skill—can be delegated only to another RN. Activities like evaluating patient teaching—which include the core of the nursing process and require specialized knowledge, judgment, and/or skill—can be delegated only to another RN. Activities like deciding to withhold medication based on vital signs—which include the core of the nursing process and require specialized knowledge, judgment, and/or skill—can be delegated only to another RN. Activities like formulating a nursing diagnosis—which include the core of the nursing process and require specialized knowledge, judgment, and/or skill—can be delegated only to another RN. DIF: Application REF: pp. 361-362

6. A student nurse is concerned about delegation practices and wonders why hospitals employ unlicensed assistive personnel (UAP) and LPN/LVNs. The student nurse refers to the National Council of State Boards of Nursing and learns that the role of these personnel is to: a. supplement the staffing pattern when an RN is not available. b. aid the RN by performing appropriately delegated care tasks. c. replace the RN when the health care facility provides long-term care. d. provide patient teaching, allowing more direct care to be provided by the RN.

B The UAP and LPN/LVN can increase productivity of the RN by performing those tasks that fall within their scope of practice. DIF: Comprehension REF: p. 353

17. Which of the following situations would be appropriate for the supervisory level of initial direction and/or periodic inspection? a. Experienced RNs work together to provide care for a group of patients newly diagnosed with meningitis. b. The RN assigns the LPN tasks within her scope of practice and checks back during the shift to ensure the tasks are completed correctly. c. A new graduate nurse is assigned care to a male patient with a hematocrit of 11.0 g of hemoglobin per deciliter and is receiving a blood transfusion. The charge nurse checks on the patient status every 15 to 30 minutes and asks the graduate to explain "next steps." d. No supervision is necessary since both are registered nurses.

B When a working relationship is established and competencies of the delegate established, the delegator may check in during intermittently during the shift. DIF: Application REF: p. 361

14. A nurse moves from California to Arkansas and due to having 20 years of experience as a registered nurse is immediately placed in charge of the telemetry unit. The staffing consists of LPNs and two unlicensed assistive personnel. The RN is unsure of the scope of practice of the LPNs and reviews the nurse practice act for Arkansas, which lacks clarity on some tasks. The RN should: a. query the state nursing association to determine their stance on the role of LPNs. b. ask the LPNs on the unit to list what tasks they routinely performed. c. contact the state board of nursing to determine legal scope of practice for LPNs. d. refer to California's nurse practice act because the scope of LPNs/LVNs is consistent across the United States.

C If the nurse practice act lacks clarity, the state board of nursing can provide guidance. DIF: Application REF: pp. 354-355

10. An RN is counseled by the nurse manager regarding inappropriate delegation when the: a. RN instructs the nursing assistant to greet ambulatory surgery patients and show them to their rooms. b. nursing assistant informs the RN that she has not been trained to collect a sputum specimen and the RN states, "I will show you this time and you can show me the next time." c. RN assigns the float LPN/LVN the task of completing a plan of care for a stable patient who was admitted for routine replacement of a feeding tube. d. LPN/LVN who has demonstrated competence is asked to perform a dressing change for a patient before she is discharged home.

C Only an RN can initiate and complete a new plan of care; this does not fall within the scope of practice of the LPN/LVN. The RN has violated one of the five rights of delegation. DIF: Application REF: p. 357

9. An LPN/LVN has transferred to a nursing unit and arrives for the first day. The RN checks with the LPN/LVN often throughout the shift to provide support and determine if assistance is needed. The RN is providing which level of supervision? a. There is no supervision, because at times the LPN/LVN is not with the RN. b. Periodic inspection is being used. Because the LPN/LVN is licensed, the RN is relieved of the need to evaluate care. c. Continual supervision is being provided until the RN determines competency. d. Initial supervision is being provided because this is the LPN/LVN's first day on the unit.

C This level of supervision is required when the working relationship is new, the task is complex, or the delegatee is inexperienced or has not demonstrated an acceptable level of competence. DIF: Comprehension REF: p. 362

8. Which task is appropriate for the RN to delegate to the unlicensed assistive personnel (UAP) provided the delegatee has had experience and training? a. Evaluate the ability of a patient to swallow ice after a gastroscopy. b. Assist a patient who is postoperative hip replacement to ambulate with a walker for the first time. c. Change the disposable tracheotomy cannula for a new postoperative tracheotomy patient if secretions are thick and tenacious. d. Obtain a sterile urine sample from a patient with a Foley catheter that is connected to a closed drainage system.

D Obtaining a sterile urine sample from a patient with a Foley catheter that is connected to a closed drainage system is not an invasive procedure, and risk to the patient is minimal, making the task appropriate for delegation. DIF: Analysis REF: pp. 357-358, Box 20-3

13. During orientation, an RN learns that LPN/LVNs in the facility receive additional training to perform some tasks such as hanging continuously infusing intravenous fluids that have no additives. It is important for the RN to understand that: a. the health care facility can override the state practice act by having all LPN/LVNs and unlicensed assistive personnel (UAP) participate in on-site training. b. LPN/LVNs are licensed, and accountability for their own practice rests with each LPN/LVN. c. UAPs cannot be held responsible for their own actions or inactions. d. the nurse practice act and state regulations related to delegation override the organization's policies.

D The state's nurse practice act is the deciding factor regarding what can legally be delegated. DIF: Comprehension REF: p. 355