While applying a warm wet soak to the client's left leg, the unlicensed assistive personnel (UAP) notes a small burn on the inside of the calf. The UAP informs the RN. Which response by the nurse is the most appropriate?
1. "Please notify the health care provider."
2. "Describe the burn in detail, please."
3. "I'll go take a look at it."
4. "Make sure you document it and complete an incident form."
3
Rationale 1: The nurse should notify the health care provider.
Rationale 2: The nurse should not rely on the UAP's description of the wound but should assess it thoroughly.
Rationale 3: Although the nurse can delegate the performance of the task, the responsibility for the task is not delegated, so the nurse should go assess the wound.
Rationale 4: The nurse should complete an incident report.
Global Rationale: Although the nurse can delegate the performance of the task, the responsibility for the task is not delegated, so the nurse should go assess the wound prior to notifying the health care provider and completing an incident report. The nurse should not rely on the UAP's description of the wound but should assess it thoroughly.
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