Delegation PrepU
A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action? Ask the client how the bag is changed. Read the policy and procedure manual. Ask a skilled nurse to assist with the procedure. Determine the necessity of the bag change.
Correct response: Ask a skilled nurse to assist with the procedure. Explanation: Professional nurses should only undertake tasks that they have been properly trained to perform. Because the nurse has no experience in changing an ostomy bag, it would be most appropriate to have the assistance of an experienced nurse. It would be inappropriate to ask the client how the bag is changed. The client is relying on the nurse to have the necessary technical knowledge. Reading the policy and procedure manual alone would not ensure the successful completion of the procedure. The necessity of the ostomy bag change has already been established.
A charge nurse has assigned a new nurse a task that the nurse has not been trained to perform. Which is the most appropriate action for the nurse to take? Consult with the charge nurse before performing the procedure. Review the procedure in the procedure manual before performing the intervention. Perform the procedure and inform the charge nurse of the results. Delegate the intervention to an unlicensed assistive personnel.
Correct response: Consult with the charge nurse before performing the procedure. Explanation: Whenever a charge nurse asks a nurse to perform an intervention for which the nurse lacks training or education, the nurse should consult with the charge nurse to determine whether the nurse should attempt to perform the intervention with supervision. Under no circumstances should a nurse attempt to perform interventions beyond the nurse's capacity without supervision, even if instructed to do so by a charge nurse. Delegating the intervention to an unlicensed assistive personnel is not an acceptable option, as the nurse is likely not familiar with the education of this individual.
Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)? Does this task fall within the scope of a UAP? What is the client's condition? How can I supervise the completion of this task? How can I explain the task to the UAP?
Correct response: Does this task fall within the scope of a UAP? Explanation: All of these questions are important, but the priority is whether the task falls within the scope of a UAP. If the answer is no, the rest of the questions are not necessary.
The registered nurse (RN) and unlicensed assistive personnel (UAP) are working together to admit a pediatric client to a nursing unit. Which task would be inappropriate for the RN to delegate to the UAP? Initiating intravenous therapy Securing the client on a papoose board Soothing the client during the procedure Gathering equipment needed for intravenous therapy
Correct response: Initiating intravenous therapy Explanation: When delegating, the RN must determine the skill level and education of the UAP, the client's condition and the complexity of that condition, and the potential for harm. Initiating intravenous therapy is reserved for the RN due to the potential for harm and the scope of the UAP. The UAP can assist the nurse by obtaining equipment, securing the client, and soothing the client.
The nurse and unlicensed assistive personnel (UAP) are working together to admit a client newly diagnosed with diabetes to a nursing unit. Which task would be inappropriate to delegate to the UAP? Measuring blood pressure Offering sugar-free popsicles Performing a fingerstick blood glucose test Monitoring insulin requirements
Correct response: Monitoring insulin requirements Explanation: When delegating, the RN must determine the skill level and education of the UAP, the client's condition and the complexity of the condition, and the potential for harm. The nurse should monitor the client's need for insulin. The UAP can monitor blood pressure, offer nourishment, and perform a fingerstick blood glucose test. The UAP should report the result of the fingerstick blood glucose test to the nurse, and the nurse should determine the need for insulin based on physician orders.
A registered nurse (RN) and a licensed practical nurse (LPN) are caring for a client who has been admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing actions can the RN delegate to the LPN? Select all that apply. Obtaining pulse oximetry Auscultating breath sounds Performing an admission assessment Developing a nursing care plan Administering an oral antibiotic
Correct response: Obtaining pulse oximetry Auscultating breath sounds Administering an oral antibiotic Explanation: It is within the scope of practice for a licensed practical nurse (LPN) to obtain pulse oximetry, auscultate breath sounds, and administer oral antibiotics. A registered nurse (RN) must perform the admission assessment and develop the nursing care plan. These are tasks that cannot be delegated because these are not in the scope of the LPN.
A new unlicensed assistive personnel (UAP) is preparing to ambulate an obese client. The registered nurse (RN) is concerned about the UAP's ability to safely ambulate the client. Which would be the nurse's most appropriate action? Tell the UAP that the RN will assist the UAP with the client's ambulation. Tell the UAP that a different UAP should ambulate the client. Tell the UAP not to ambulate the client at this time. Tell the UAP to ask the client whether the client is comfortable with the UAP assisting ambulation.
Correct response: Tell the UAP that the RN will assist the UAP with the client's ambulation. Explanation: The client's safety is always the nurse's primary concern. If the nurse believes that the UAP is unable to safely ambulate the client at this time, the nurse could offer assistance. By assisting the UAP, the nurse ensures the client's safety while still allowing the new UAP to learn. Having a different UAP ambulate the client or instructing the UAP not to ambulate the client does not assist the UAP in learning. Asking the client whether the client feels comfortable having the UAP ambulate the client is inappropriate.
A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action? The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. The nurse should ask another nurse who was previously assigned to the client for instruction. The nurse should request that the blood transfusions be delayed until the next shift. The nurse should recognize the necessity of the assignment and provide care to the best of the nurse's ability.
Correct response: The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. Explanation: The nurse should recognize that the nurse lacks the competence to safely care for a client with these complex needs and inform the charge nurse of the fact. This assignment would be an inappropriate delegation on the part of the charge nurse and could cause injury to the client. The other options do not take the safety of the client into consideration.
