Situation: The nurse works on a 30-bed acute psychiatric uni… | 마이메르시 MyMerci
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Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations
문제

Situation: The nurse works on a 30-bed acute psychiatric unit of a general hospital. The interprofessional team includes psychiatrists, nurses, a psychologist, a social worker, an occupational therapist and trained nursing attendants. The team meets every morning. The nurse is in charge of eight clients with one trained nursing attendant on duty. Each task below is on the nursing attendant's job description. Which task may the nurse delegate to the nursing attendant now?

해설
A task on the job description is delegated only in the right circumstance: a stable client with a predictable outcome. A new symptom after a recently started drug, coughing when drinking, and a recent parenteral sedative each make the client unstable or at risk, so the nurse keeps those tasks. Recording intake and output for a stable client is routine, and the nurse interprets the values and stays accountable for the decision to delegate.
같은 주제 다음 문제Situation: The nurse works on a 30-bed acute psychiatric unit of a general hospital. The i…이 문제가 수록된 문제집PLNE Question Bank 150014,000원 · 무료 체험 가능

심화 해설

Delegate only stable, predictable tasks
Every task listed is on the nursing attendant's job description, so the question is whether the circumstances make delegation safe now. Delegation follows the rights of delegation: the right task, circumstance, person, communication, and supervision. A task is delegated when the client is stable and the outcome predictable; recording intake and output for a stable client on lithium meets this standard. The attendant measures and records the values, while the nurse interprets them and remains accountable for the decision to delegate.

Why each of the other tasks stays with the nurse
Taking vital signs is usually delegable, but a client on day 2 of clozapine who now feels faint may have orthostatic hypotension, a dysrhythmia, or another serious adverse effect, and needs the nurse's own assessment. Feeding a client with dementia is delegable only when there is no swallowing difficulty; coughing with each drink signals aspiration risk and calls for nursing assessment and possibly a swallowing evaluation. Walking a client to the garden is delegable for stable clients, but 30 minutes after an intramuscular sedative the response is unpredictable and the fall risk is high.

TaskClient conditionDelegate now?
Vital signsDay 2 of clozapine, feels faintNo: unstable, needs assessment
FeedingDementia, coughs with each drinkNo: aspiration risk
Intake and outputStable, on lithiumYes
Ambulation to garden30 minutes after IM sedativeNo: unpredictable, fall risk

Why intake and output matter for lithium
Lithium has a narrow therapeutic range and is excreted by the kidneys. Dehydration, sodium loss, and reduced fluid intake raise lithium levels and the risk of toxicity. Accurate intake and output records help the nurse detect fluid imbalance early. Collecting the data is routine and repeatable, but recognizing a worrying pattern and acting on it require nursing judgment.

Watch out! A task being on a job description does not make it delegable in every situation. Look for words in the stem such as "new", "now feels", "coughs", or "just received" that signal instability or an unpredictable response.

Exam takeaway
Key point! Delegate routine tasks for stable clients with predictable outcomes; keep assessment, interpretation, and care of unstable clients. The nurse remains accountable for delegated tasks and supervises their completion.

임상 시나리오

Safe DelegationMatching tasks to stable clients

Delegate when the client is stable and the outcome predictable. Recording intake and output for a stable client on lithium qualifies; the nurse interprets the values.

Keep tasks involving new symptoms after a recently started drug, aspiration risk, or a recent IM sedative. These clients need nursing assessment.

The nurse remains accountable for the decision to delegate and supervises completion.

Caution

A task on the job description is not delegable when the client's condition makes the outcome unpredictable.

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