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A 69-year-old woman is admitted with dizziness, confusion, and dyspnea. Which vital sign should not be delegated to trained ancillary personnel?

A.

Temperature

B.

Pulse

C.

Respiratory rate

D.

Blood pressure

Answer and Explanation

The Correct Answer is C

In cases where a client presents with acute symptoms, the nurse must use clinical judgment to determine whether vital sign assessment requires nursing-level evaluation, particularly for parameters that require observation, interpretation, or correlation with clinical symptoms.

Rationale for correct answer:

C. Respiratory rate is the most sensitive indicator of deterioration and must often be assessed by a nurse, especially in clients with dyspnea or altered mental status.

 

Rationale for incorrect answers:

A. Temperature: Taking temperature is a simple, objective task that is appropriate to delegate to trained personnel.

B. Pulse can generally be delegated, especially when using automated equipment.

D. Blood Pressure is usually safe to delegate to trained personnel. While the nurse should evaluate the results, the act of measuring BP (especially with an automated device) does not require advanced assessment skills unless there's an abnormality.

 

Take-home points:

  • Respiratory rate is often under-assessed but is critical for identifying early clinical deterioration, especially in clients with dyspnea or confusion.
  • Delegation decisions must always factor in client stability, the complexity of the task, and the skill level required to interpret findings.


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Related Questions

Correct Answer is A

Explanation

Monitoring and interpreting body temperature is a fundamental nursing task used to assess homeostasis, detect infection, and guide treatment decisions. The normal oral temperature range for adults is typically between 3F.5°C to 37.5°C (97.7°F to 99.5°F).

Rationale for correct answer:

A. Fever (also called pyrexia) is defined as a body temperature above the normal range, typically greater than 38°C (100.4°F) when measured orally.

Rationale for incorrect answers:

B. Hypothermia refers to a core body temperature below 35°C (95°F).

C. Hypertension refers to elevated blood pressure, not body temperature.

D. Afebrile means without fever, or having a normal body temperature.

Take-home points:

  • A temperature above 38°C (100.4°F) is classified as a fever and should be documented accordingly.
  • Use accurate terminology for vital signs to ensure clear communication and proper follow-up care.

Correct Answer is C

Explanation

In cases where a client presents with acute symptoms, the nurse must use clinical judgment to determine whether vital sign assessment requires nursing-level evaluation, particularly for parameters that require observation, interpretation, or correlation with clinical symptoms.

Rationale for correct answer:

C. Respiratory rate is the most sensitive indicator of deterioration and must often be assessed by a nurse, especially in clients with dyspnea or altered mental status.

Rationale for incorrect answers:

A. Temperature: Taking temperature is a simple, objective task that is appropriate to delegate to trained personnel.

B. Pulse can generally be delegated, especially when using automated equipment.

D. Blood Pressure is usually safe to delegate to trained personnel. While the nurse should evaluate the results, the act of measuring BP (especially with an automated device) does not require advanced assessment skills unless there's an abnormality.

Take-home points:

  • Respiratory rate is often under-assessed but is critical for identifying early clinical deterioration, especially in clients with dyspnea or confusion.
  • Delegation decisions must always factor in client stability, the complexity of the task, and the skill level required to interpret findings.

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