An interdisciplinary team is considering whether to apply the principle of paternalism in the care of a client.
What query should guide the team's decision?

Choice A rationale

Measuring intake and output is a basic data collection task that does not require nursing judgment or clinical analysis. Under the principles of delegation, a UAP can perform this task for stable patients. The RN remains responsible for analyzing the numerical data to evaluate the effectiveness of rehydration therapy. Dehydration involves fluid volume deficit where normal urine output is typically 30 mL to 60 mL per hour.

Choice B rationale

Assisting with ambulation is a standard task for UAPs and LPNs when the patient is clinically stable. Postoperative knee replacement patients require movement to prevent venous thromboembolism. If the patient is early in their recovery or unstable, the RN must perform the initial assessment. However, routine assistance with walking is appropriate for delegation as it focuses on physical support rather than complex clinical assessment of the surgical site.

Choice C rationale

Reinforcing teaching is a specific competency within the LPN scope of practice. While the RN must perform the initial education and assessment of the patient's learning needs regarding heart failure and sodium restrictions, the LPN can remind the patient of these instructions. This reinforcement helps solidify the patient's understanding of dietary triggers for fluid retention and exacerbation of heart failure symptoms, supporting the overall plan of care.

Choice D rationale

Monitoring a stable patient is within the scope of both LPNs and UAPs, depending on the specific observation required. For a patient with a history of seizures who is currently stable after a procedure, the LPN can monitor for signs of seizure activity or changes in consciousness. The RN must still perform the primary neurological assessments, but the delegation of routine observation ensures patient safety while the RN manages more complex tasks.

Choice E rationale

Administering oral medications to stable patients is a core function of the LPN. The LPN is trained to verify the five rights of medication administration and monitor for basic side effects. In a postoperative context, once the patient is stable and cleared for oral intake, the LPN can safely provide scheduled medications. The RN retains the responsibility for managing intravenous medications, blood products, and any complex titration required by the patient.

Choice F rationale

Changing a central venous catheter dressing is a sterile, complex procedure that is generally reserved for the RN in many facility policies due to the high risk of central line associated bloodstream infections. This task involves assessing the insertion site for signs of infection and maintaining strict aseptic technique. Because of the potential for significant complications and the need for advanced clinical judgment, it is not typically delegated to UAPs or LPNs.

Choice A rationale

Collecting a sterile sputum specimen from a ventilated patient is a necessary task but does not represent an immediate life-threatening emergency. While maintaining airway patency and monitoring ventilator settings are high priorities, this patient is currently supported by mechanical ventilation. The specimen collection can be momentarily deferred while the nurse addresses patients experiencing acute, worsening respiratory distress that is not yet stabilized by mechanical means or effective medication.

Choice B rationale

Starting intravenous antibiotics for a pneumonia patient is a high priority to treat the underlying infection and prevent sepsis. However, this is a scheduled intervention rather than an acute change in status. Antibiotics should be given within the prescribed timeframe to maintain therapeutic blood levels. Compared to a patient experiencing a sudden asthma exacerbation that is not responding to rescue inhalers, the pneumonia patient is relatively more stable for the initial few minutes.

Choice C rationale

A pulse oximetry reading of 90 percent is often considered an acceptable baseline for a patient with chronic obstructive pulmonary disease. These patients frequently live in a state of chronic hypoxemia, and their drive to breathe is often triggered by low oxygen levels rather than high carbon dioxide. Since this reading was from the previous shift and is expected for the disease process, this patient does not require the most immediate assessment.

Choice D rationale

This patient is the highest priority because they are demonstrating signs of an acute asthma exacerbation that is refractory to bronchodilator therapy. Shortness of breath after using a rescue inhaler suggests a potential status asthmaticus or severe airway narrowing that could lead to respiratory arrest. This represents a failure of the standard emergency treatment and requires immediate nursing assessment of lung sounds, work of breathing, and potential escalation of care to maintain the airway.