The nurse delegates vital signs for a patient to the nurse assistant. What is the nurse's responsibility regarding delegation of this task?
The nurse should review the patient's vital signs as soon as they are done.
The nurse assistant should not be responsible for obtaining vital signs.
The nurse is not responsible if the nurse assistant fails to obtain the vital signs.
The nurse assistant should determine if the patient's vital signs are abnormal.
The Correct Answer is A
A. The nurse should review the patient's vital signs as soon as they are done. Even though vital signs can be delegated, the nurse retains accountability for assessing the data, interpreting abnormalities, and determining if further action is needed.
B. The nurse assistant should not be responsible for obtaining vital signs. Nurse assistants can take vital signs if they are properly trained and it is within their scope of practice. However, the nurse remains responsible for interpreting and acting on the results.
C. The nurse is not responsible if the nurse assistant fails to obtain the vital signs. The nurse remains accountable for delegated tasks and must ensure they are completed correctly.
D. The nurse assistant should determine if the patient's vital signs are abnormal. Nurse assistants can report abnormal findings, but they are not responsible for interpreting results or making clinical decisions—this is the nurse’s responsibility.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Record the pulse as "0" (zero) for that site. A pulse should never be documented as absent without first using a Doppler device to confirm whether blood flow is present.
B. Use a Doppler device to locate and assess the pulse. If a pulse is difficult to palpate, a Doppler ultrasound should be used to detect blood flow before making any conclusions about circulation status.
C. Come back in 15 minutes and reassess. If the pulse is weak or difficult to locate, immediate assessment with a Doppler is needed instead of delaying evaluation.
D. Report the finding to the physician. While a physician should be notified if a pulse remains undetectable even with a Doppler, the nurse must first verify the absence of a pulse before escalating the concern.
Correct Answer is D
Explanation
A. Temperature, pulse, respirations, BP. While these are standard vital signs, they do not include oxygen saturation or pain level, both of which are critical in a patient with chest pain.
B. Temperature, pulse, respirations, BP, pain. Pain is an essential assessment, especially for chest pain, but oxygen saturation should also be measured to assess for hypoxia, which can contribute to cardiac symptoms.
C. BP, respirations, temperature, pulse. This option omits both oxygen saturation and pain level, which are essential in evaluating cardiac and respiratory function in a patient presenting with chest pain.
D. Temperature, pulse, respirations, blood pressure, O2 sat, pain. This option includes all critical assessments for a patient with chest pain. Oxygen saturation helps assess respiratory and circulatory efficiency, and pain assessment is vital in determining the severity and possible cause of the chest pain.
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