The ICU nurse is assigned to provide nursing care to a client receiving mechanical ventilation. Which action should you delegate to the experienced unlicensed assistive personnel (UAP)?

Choice A reason: The ability to prioritize is important for the overall management of tasks, but it is not the most critical factor when considering the delegation of specific tasks to assistive personnel.

Choice B reason: The knowledge and skill to perform the task is crucial when delegating tasks to assistive personnel. Ensuring that the AP has the appropriate training and competence to carry out the task safely and effectively is essential to maintaining high standards of care.

Choice C reason: Rapport with clients is important for building trust and effective communication, but it is secondary to having the necessary skills and knowledge to perform delegated tasks.

Choice D reason: While the ability to complete the task without assistance is beneficial, it is more important that the assistive personnel have the required knowledge and skills to perform the task correctly and safely.

Choice A reason: The statement "The client fell out of bed" is an assumption and not an objective observation. Documentation should include only factual information that is observed or measured, rather than conclusions or suppositions. Therefore, this statement should not be included in the incident report.

Choice B reason: Documenting the client's vital signs is crucial as it provides measurable data about the client's condition at the time of the incident. Recording blood pressure, pulse, and respirations helps to establish a baseline and can be used for future comparison to assess any changes in the client's status after the incident. This is a factual and objective piece of information that is appropriate for the incident report.

Choice C reason: Noting that no bruises or injuries were observed on the client is an important observation. This statement provides an objective assessment of the client's physical condition immediately after the fall, which is critical for ongoing monitoring and care. It helps to document that the client did not sustain visible injuries during the incident.

Choice D reason: The statement "The client apparently climbed over the side rails unwitnessed" includes speculation and is not based on direct observation. Documentation should avoid including subjective interpretations or assumptions about the events. Only witnessed and factual information should be recorded in the incident report to maintain accuracy and objectivity.

Choice E reason: Reporting that the health care provider was notified of the incident is essential for ensuring continuity of care. This statement documents the communication between the nurse and the provider, which is a critical step in the incident response process. It ensures that appropriate follow-up actions can be taken based on the provider's assessment and recommendations.