The nurse is busy with the admission of four clients to the acute care unit. Which actions by the nurse indicate that inappropriate delegation to an unlicensed assistive personnel (UAP) has occurred? Select all that apply.
The nurse asks the UAP to administer acetaminophen for a client that has a temperature of 102°F (38.9°C) and a headache.
The nurse asks the UAP to evaluate the results of the previous administration of furosemide given for peripheral edema.
The nurse informs the UAP to assess the client for signs and symptoms of a urinary tract infection when collecting urine.
The nurse asks the UAP to measure intake and output for a client with chronic kidney failure.
The nurse asks the UAP to auscultate lung sounds on a client admitted with pulmonary edema and report findings.
Correct Answer : A,B,C,E
Delegation in nursing is governed by scope of practice, accountability principles, clinical judgment requirements, and patient safety standards, where tasks requiring assessment, evaluation, or clinical interpretation cannot be assigned to unlicensed assistive personnel due to lack of licensure and diagnostic authority.
Rationale:
A. Administration of acetaminophen is a medication-related task that requires licensed nursing judgment, especially in a febrile patient at 38.9°C. UAPs are not permitted to administer medications, making this inappropriate delegation and a violation of scope of practice.
B. Evaluating the effects of furosemide requires clinical assessment of fluid status, electrolyte balance, and therapeutic response. This is an evaluative nursing function involving clinical judgment, which cannot be delegated to UAPs under nursing practice regulations.
C. Assessing for urinary tract infection signs and symptoms involves clinical interpretation of findings such as dysuria, fever, and urinary changes. This is a nursing assessment activity requiring critical thinking, making it inappropriate for delegation to UAPs.
D. Measuring intake and output is a basic, noninvasive task within UAP scope. It involves data collection only without interpretation or clinical judgment. This task is appropriate delegation in stable or chronic conditions such as renal disease.
E. Auscultating lung sounds requires trained clinical skill and interpretation of respiratory findings such as crackles or diminished breath sounds. This is an assessment function requiring nursing licensure, making it inappropriate for delegation to UAPs.
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Related Questions
Correct Answer is D
Explanation
The epidemiological triangle is a core model in infectious disease epidemiology used to explain disease causation and transmission through the interaction of three essential components: host susceptibility, infectious agent characteristics, and environmental conditions that support survival and spread of disease in populations.
Rationale:
A. Person, place, and time describe the epidemiologic descriptive triad, which is used to characterize disease distribution patterns in populations. It is not a causation model but rather a surveillance tool for identifying when, where, and in whom disease occurs.
B. Biological, sociological, and physical dimensions represent broad determinants of health, often used in social epidemiology. This framework does not specifically explain infectious disease transmission dynamics or agent-host-environment interaction.
C. Multiple risk factor causality refers to the concept that diseases result from interacting risk factors rather than a single cause. While important in chronic disease epidemiology, it is not the structure of the epidemiological triangle model.
D. Host, agent, and environment form the epidemiological triangle, the correct model used to explain infectious disease transmission such as measles and HIV. It demonstrates how disease occurs through interaction between a susceptible host, an infectious agent, and environmental conditions.
Correct Answer is B
Explanation
Effective delegation requires continuous supervision and clear communication between the nurse and unlicensed assistive personnel (UAP). When a delegated task is not completed, the nurse must engage in re-evaluation to identify barriers, ensure accountability, and maintain the integrity of the nursing process.
Rationale:
A. Completing the task yourself undermines the delegation process and encourages future role confusion. While the specimen is important, the nurse's priority is to manage the personnel they are supervising to ensure team efficiency. This action fails to address the underlying issue of non-compliance.
B. Providing direct feedback allows the nurse to investigate why the task was not performed and correct the behavior. This is the priority because it promotes professional growth and identifies if the UAP faced unforeseen clinical obstacles. Communication is the key to maintaining accountability.
C. Issuing a verbal warning as a first step is an aggressive management style that bypasses necessary inquiry. A nurse should first determine if the UAP lacked the resources or understanding to complete the collection. Discipline should only follow if corrective feedback fails to resolve the issue.
D. Asking another nurse to perform a UAP's task is an inappropriate use of clinical resources and shifts the burden to another professional. This avoids the conflict rather than resolving it and disrupts the workflow of the entire unit. It fails to hold the original delegate accountable.
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