A nurse is working on a medical unit, and assigns a nurse's aide to take vital signs for several clients. The aide completes this task and documents them accordingly
One of the clients had a blood pressure reading of 180/110, and it wasn't until the end of the shift that the nurse was apprised of this value. The physician was notified, and orders were received for treatment, but not until much later in the shift. Which responsibility of delegation did the nurse fail to carry out?
1. Delegating to the appropriate staff.
2. Delegating the appropriate task.
3. Selecting the appropriate client.
4. Appropriately supervising care.
Correct Answer: 4
Rationale 1: The nurse did delegate to the appropriate staff, since securing vital signs is within the scope of practice for a nurse's aide.
Rationale 2: The nurse did delegate an appropriate task, since securing vital signs is within the scope of practice for a nurse's aide.
Rationale 3: There was no indication given that the clients were not appropriately selected for this task.
Rationale 4: The nurse has two responsibilities in delegating and assigning duties: (1) appropriate delegation of duties (that is, giving people duties within their scope of practice) and (2) adequate supervision of personnel to whom work is delegated or assigned. In this situation, the nurse gave an unlicensed person a duty that was appropriate. The aide completed the duty and documented the findings. The nurse is still responsible for analyzing data, planning care, and evaluating outcomes. In this case, the nurse failed to follow up (supervise) after the duty was performed and analyze the findings.
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