To satisfy duty of care to a patient, a nurse manager is legally responsible for all of the following except:

Choice A rationale

Teaching is a core component of the nursing process and requires professional judgment, specialized knowledge, and the ability to evaluate the patient's understanding and technique. Unlicensed assistive personnel do not have the educational background to provide initial education or complex clinical instructions. Delegating teaching to a UAP is unsafe and outside their scope of practice because they cannot assess the patient's respiratory status or effectiveness of the incentive spirometry therapy.

Choice B rationale

Assisting with ambulation using a gait belt for a stable postoperative patient is a standard task that can be delegated to UAPs. Since the surgery was yesterday and the patient is ready for movement, the UAP provides physical support to ensure safety. The nurse remains responsible for the initial assessment of the patient's gait and strength, but the repetitive task of assisting with walking to maintain mobility is appropriate for trained unlicensed staff.

Choice C rationale

Hygiene and mobility assistance, including bed baths and repositioning, are fundamental tasks within the UAP scope of practice. For a stable patient with limited mobility, these activities are essential for preventing pressure ulcers and maintaining skin integrity. The UAP is trained to perform these tasks safely while following the turn schedule. This allows the registered nurse to focus on more complex clinical assessments and interventions that require advanced nursing judgment.

Choice D rationale

Medication administration, including oral antibiotics, is a task that requires an understanding of pharmacology, potential side effects, and the rights of medication administration. In most jurisdictions, UAPs are strictly prohibited from administering medications as they lack the licensure to monitor for adverse reactions or assess the therapeutic efficacy of the drug. This task must be performed by a licensed nurse to ensure patient safety and adherence to legal practice standards.

Choice E rationale

Obtaining vital signs for a stable patient is a common technical task delegated to UAPs. Because this patient is stable and awaiting discharge, the risk of rapid clinical deterioration is low, making the data collection appropriate for unlicensed personnel. However, the nurse must still review the values to ensure they fall within the normal range, such as a blood pressure less than 120÷80 mmHg, before the patient is allowed to leave.

Choice A rationale

Documentation of nonadherence is a standard nursing responsibility, but notifying the provider immediately without first exploring the underlying cultural or physiological reasons for the behavior does not fully promote quality care. Nurses must understand that blood pressure medication side effects, such as dizziness, often lead to discontinuation. In hypertension, normal systolic range is < 120 mmHg and diastolic is < 80 mmHg. Addressing the root cause rather than just labeling the patient as noncompliant fosters a better therapeutic relationship and improves long-term safety outcomes.

Choice B rationale

Collaboration with the healthcare provider is essential because the patient reported dizziness, a common side effect of antihypertensive therapy which can lead to falls. Adjusting the dosage or class of medication may alleviate side effects while maintaining blood pressure within the normal range of 90 ÷ 60 mmHg to 120 ÷ 80 mmHg. This scientific approach ensures that the pharmacological intervention is tailored to the patient's specific physiological tolerance, thereby increasing the likelihood of adherence and reducing the risk of stroke or cardiac events.

Choice C rationale

Professional medical interpreters are vital for ensuring accurate communication of complex medical information and cultural nuances. Language barriers can lead to significant misunderstandings regarding medication instructions and the pathophysiology of hypertension. Utilizing an interpreter ensures that the patient's traditional healing practices are accurately conveyed to the healthcare team. This promotes safety by preventing errors that occur when using family members or untrained staff, ensuring the patient understands that high blood pressure can lead to organ damage if not managed correctly.

Choice D rationale

Assessing the patient's health literacy and understanding of hypertension is a foundational step in the nursing process. Hypertension is often a silent killer because it may not present symptoms until significant vascular damage occurs. By evaluating what the patient believes about their condition and herbal remedies, the nurse can provide targeted education. This allows the nurse to explain how prescribed medications work at the cellular level to reduce peripheral vascular resistance, helping the patient make informed decisions that align with both their cultural values and safety requirements.

Choice E rationale

Instructing a patient to immediately stop all traditional herbal remedies can alienate them and damage the nurse-patient relationship, especially in cultures where traditional healing is highly valued. Scientifically, it is important to first identify the specific herbs being used to check for potential drug-to-drug interactions with antihypertensives. A more effective safety approach is to facilitate a dialogue between the patient, the traditional healer, and the provider to integrate safe practices rather than issuing an ultimatum that the patient may likely ignore.