The nurse assigns unlicensed assistive personnel to measure vital signs for several clients. The task is completed and documented correctly; however, one of the clients had a blood pressure reading of 180/110

Question

The nurse learns this information at the end of 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

Answer 1

Correct Answer: 4
Rationale 1: The nurse did delegate to the appropriate staff, as securing vital signs is within the scope of practice for unlicensed assistive personnel.
Rationale 2: The nurse did delegate an appropriate task, as securing vital signs is within the scope of practice for unlicensed assistive personnel.
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. Unlicensed assistive personnel 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.