A patient with heart failure is one-day postoperative for major abdominal surgery. When the nurse and the assistive personnel raise the head of the bed to sit the patient on the side of the bed before ambulation, the patient immediately complains of dizziness and nausea. What are your immediate actions? Select all that apply

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.

According to the ANA and NCSBN guidelines, UAPs can take vital signs in stable clients, but the nurse is still responsible for interpreting the findings and taking action when needed. For clients who are unstable, newly admitted, or receiving high-risk treatments, vital signs should be taken by the nurse to allow for immediate clinical judgment.

Rationale for correct answer:

A. A client being prepared for elective facial surgery with a history of stable hypertension: This client is clinically stable and undergoing a planned, non-emergency procedure. The history of stable hypertension implies no acute instability, making it appropriate for the UAP to collect vital signs.

Rationale for incorrect answers:

B. A client receiving a blood transfusion with a history of transfusion reactions: This client is high risk due to a known history of transfusion reactions. Vital signs need to be monitored closely and frequently by a licensed nurse who can recognize early signs of a reaction.

C. A client recently started on a new antiarrhythmic agent: Starting a new antiarrhythmic introduces potential for serious adverse effects, including bradycardia, hypotension, or arrhythmias.

D. A client who is admitted frequently with asthma attacks: Although this client may be familiar to the unit, frequent asthma exacerbations place them at risk for acute respiratory deterioration. Vital signs should be taken by the nurse to assess signs of distress.