When the nurse delegates measurement of vital signs to unlicensed assistive personnel (UAP), which are the nurse's responsibilities?
1. Assessment of vital sign readings obtained by UAP
2. Assessment of the UAP's skills in measuring vital signs
3. Determination that the vital signs were obtained correctly
4. Follow up on vital sign measurements that are abnormal or unexpected
5. Observe the UAP as vital signs are being measured
1, 2, 3, 4
Rationale 1: The nurse should review and assess all vital sign readings.
Rationale 2: The nurse should determine that the UAP is competent to perform any task delegated.
Rationale 3: The nurse should assess the UAP's competence while performing the task.
Rationale 4: If the UAP reports an unusual reading, the nurse should recheck the vital sign to determine that it is accurate before treating or responding to the reading.
Rationale 5: The nurse does not need to follow the UAP around once judged to be competent.
Global Rationale: Although the nurse can delegate the performance of tasks, the responsibility for those tasks is not delegated, and rests with the nurse. The nurse should review and assess all vital signs. The nurse should determine that the UAP is competent to perform any task delegated and should assess the UAP's competence while performing the task. If the UAP reports an unusual reading, the nurse should recheck the vital sign to determine that it is accurate before treating or responding to the reading. The nurse does not need to follow the UAP around once judged to be competent.
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