# A client admitted yesterday with exertional heat stroke was cooled in the emergency department. Today: T 37.4 C, HR 88/min, BP 126/74 mm Hg, alert and oriented. Creatine kinase 18,400 units/L (9,200 units/L yesterday). IV fluids at 250 mL/hr with a urine output goal of at least 200 mL/hr. At 0700 the client became dizzy and pale when standing, was helped back to bed, and has not been up since; the RN has not yet reassessed this. Which tasks can the RN delegate to the assistive personnel (AP)? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617265&lang=en  
> language: en  
> subject: Assignment/Delegation/Supervision  
> category: MOC

## Question

A client admitted yesterday with exertional heat stroke was cooled in the emergency department. Today: T 37.4 C, HR 88/min, BP 126/74 mm Hg, alert and oriented. Creatine kinase 18,400 units/L (9,200 units/L yesterday). IV fluids at 250 mL/hr with a urine output goal of at least 200 mL/hr. At 0700 the client became dizzy and pale when standing, was helped back to bed, and has not been up since; the RN has not yet reassessed this. Which tasks can the RN delegate to the assistive personnel (AP)? Select all that apply.

1

Weigh the client on the standing scale at 0900 as scheduled

2

Empty the urine bag hourly and record the volume on the flow sheet

3

Tell the RN right away if any hourly urine volume is below 200 mL

4

Take vital signs every 4 hours and report any heart rate above 110

5

Give the client a bed bath and change the linens after breakfast

6

Help the client walk to the bathroom for the first time since 0700

## Explanation

The client's current vital signs are stable, so routine measuring, recording, reporting against set parameters, and hygiene care in bed can be delegated to AP. Weighing on a standing scale and walking to the bathroom are normally delegable, but both require the client to stand, and the dizzy, pale episode at 0700 has not been reassessed, so the first time up needs RN assessment of orthostatic tolerance.

## In-depth explanation

Quick answer
Delegate hourly urine emptying and recording, reporting low urine output, vital signs every 4 hours with a report threshold, and the bed bath.

Why this is correct
The admitting diagnosis sounds unstable, but today's data show a stable client (T 37.4 C, HR 88, BP 126/74, alert). Tasks done with the client in bed, with clear parameters and predictable outcomes, are delegable. The detail that changes two usually delegable tasks is the unassessed orthostatic episode: anything that requires standing waits for the RN.

Easy analogy or mental picture
AP are the measuring tape and alarm bell for a stable client in bed; the first time the client stands after fainting-type symptoms, the RN is the spotter.

Memory hook
In bed + stable + clear parameters = AP. First time standing after a dizzy spell = RN.

NCLEX decision rule
Decide delegation from the client's current status and any unassessed change, not from the task name alone or the admitting diagnosis.

Why the other choices are wrong
Weighing a client on a standing scale is one of the most commonly delegated tasks, which makes it tempting, but this client has not stood since becoming dizzy and pale and the RN has not reassessed orthostatic tolerance. Helping the client walk to the bathroom is also routinely delegable, yet the first ambulation after this episode requires RN assessment of orthostatic vital signs and fall risk before AP can assist.

References
1NCSBN/ANA National Guidelines for Nursing DelegationRNs may delegate routine tasks with predictable outcomes for stable clients but not assessment or judgment
2StatPearls: RhabdomyolysisAggressive IV fluids with close urine output monitoring are central to rhabdomyolysis care

## Clinical scenario

Scenario
A client recovering from heat stroke is now hemodynamically stable but had an orthostatic episode that the RN has not yet reassessed.

## Key concepts

- **Rhabdomyolysis** — Muscle breakdown releasing myoglobin and CK that can injure the kidneys.
- **Delegation** — Transferring a specific task to AP while the RN keeps accountability for the outcome.
- **Orthostatic hypotension** — A drop in blood pressure on standing that causes dizziness and fall risk.

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