The nurse is caring for a newly admitted client.
Which task can the nurse delegate to the unlicensed assistive personnel (UAP)?
The nurse is caring for a newly admitted client.
Which task can the nurse delegate to the unlicensed assistive personnel (UAP)?
A. apply a nasal cannula to initiate oxygen at 2 L/min per standing order
[5%]
B. discontinue an IV catheter from a nonfunctioning peripheral site
[3%]
C. check capillary refill and report findings to the nurse
[1%]
D. obtain a full set of vital signs every four hours
[90%]
Statistics
Subject/Lesson
Subject
Leadership & Management
Lesson
Assignment/Delegation
Client Need
Test Plan
Management of Care
Related Topic
Assignment, Delegation and Supervision
Item Type
Item Type
Application
Explanation
Choice D is correct. Routine vital sign collection is a clearly appropriate task for UAPs, assuming the client is stable. The RN retains responsibility for analyzing the data, but the task itself meets the criteria of Right Task and Right Circumstance for delegation.
Choice A is incorrect. Initiating oxygen therapy involves administering a medication, which requires clinical judgment, a nursing license, and ongoing monitoring. It is not appropriate to delegate this task to a UAP, regardless of standing orders.
Choice B is incorrect. Removing vascular access devices can lead to complications such as bleeding or catheter fracture and requires assessment and clinical training. This task must be performed by licensed nursing personnel.
Choice C is incorrect. Capillary refill is a clinical assessment, not a basic observation. While it seems simple, interpreting perfusion status requires nursing knowledge. Delegating this to a UAP is inappropriate because assessment cannot be delegated under the Nurse Practice Act.
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2 Key Topics
UAP Delegation
