Which aspect of health assessment does the nurse delegate to the nursing assistant?
1. Auscultate apical pulse of client with acute angina.
2. Take vital signs of client with an arterial occlusion.
3. Complete lung assessment of client with pneumonia.
4. Clarify effects of antihypertensive therapy for client.
2
2. The nurse completes assessment, diagnosis, planning, and evaluation from the nursing process and receives assistance with data gathering and implementation from the nursing assistant, so the nurse delegates vital signs for the client with an arterial occlusion because the nursing assistant receives training to perform this task. In addi-tion, this client is the most stable and presents a smaller need for a nursing assessment than the remaining clients do.
1. The client with acute angina needs a nursing assessment to avert complications of impaired coronary artery blood flow. The nurse evaluates the client to complete a nursing assessment and implement indicated therapy without delay.
3. The nurse assesses the client with pneumonia to auscultate breath sounds and to evaluate the airway and oxygenation because the lungs fill with infectious exudate, impairing ventilation and increasing the risk of airway occlusion.
4. The nurse evaluates the client's antihypertensive therapy as part of the client's plan of care and the nursing process; the nurse evaluates nursing care to determine the ef-ficacy of the care.
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