1000 milliliters (mL) of 0.9 If the fluid is started at 0900, at what time is the nurse expected to hang a new bag?

Step 1 is 1000 mL ÷ 125 mL/hr = 8 hr.

Step 2 is 0900 + 8 hr = 1700. Final calculated answer is 1700.

Choice A rationale

Evaluating a client's response to medication is a complex nursing function that requires clinical judgment, knowledge of pharmacology, and assessment skills. This task involves comparing the expected therapeutic effects with the actual outcomes and identifying any adverse reactions. Because evaluation is a core component of the nursing process (ADPIE), it cannot be delegated to unlicensed assistive personnel. The registered nurse is responsible for interpreting data and making decisions about the effectiveness of the treatment plan for the patient.

Choice B rationale

Taking and reporting routine vital signs is a standard task that can be safely delegated to unlicensed assistive personnel in stable situations. This task is procedural and does not require advanced clinical judgment to perform the measurement itself. However, the nurse remains responsible for interpreting the results and determining if they are within normal limits for the specific patient. Normal ranges include blood pressure < 120/80 mmHg, heart rate 60 to 100 beats, and respiratory rate 12 to 20.

Choice C rationale

Developing a teaching plan for discharge involves assessing the learner's needs, identifying goals, and selecting appropriate educational strategies. This is a highly individualized process that requires professional knowledge of disease processes and teaching-learning principles. Unlicensed personnel do not have the training to create or modify care plans or educational materials. The registered nurse must lead the discharge planning process to ensure that the patient receives accurate and comprehensive information necessary for safe care at home.

Choice D rationale

Assessing a client's level of pain after surgery is a professional nursing responsibility that involves more than just asking for a number on a scale. It requires an understanding of the surgical procedure, potential complications, and the timing of analgesic administration. The nurse must interpret the pain within the clinical context of the patient's recovery. Since assessment is the first step of the nursing process and requires clinical judgment, it is not appropriate to delegate to unlicensed staff.