# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630058  
> language: ko  
> subject: 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?

## 보기

1. Take the vital signs of a client on day 2 of clozapine who now feels faint
2. Help a client with dementia to eat, who coughs each time he drinks
3. Record the intake and output of a stable client on lithium **✔ 정답**
4. Walk a client to the garden 30 minutes after an intramuscular sedative

**정답: 3**

## 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.

## 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.

| Task | Client condition | Delegate now? |
| --- | --- | --- |
| Vital signs | Day 2 of clozapine, feels faint | No: unstable, needs assessment |
| Feeding | Dementia, coughs with each drink | No: aspiration risk |
| Intake and output | Stable, on lithium | Yes |
| Ambulation to garden | 30 minutes after IM sedative | No: 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.

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

## 핵심 개념

- **Delegation** — Assigning a task to a qualified worker while the nurse retains accountability for the outcome.
- **Rights of delegation** — The right task, circumstance, person, communication, and supervision.
- **Lithium** — A mood stabilizer with a narrow therapeutic range whose level rises with dehydration or sodium loss.
- **Clozapine** — An antipsychotic that can cause orthostatic hypotension, agranulocytosis, myocarditis, and seizures.

## 같은 주제 문제

- [Situation: The nurse works on a 30-bed acute psychiatric unit of a general hospital. The i…](https://mymerci.kr/pages/nclex_q.php?qn_id=630056)
- [Situation: The nurse works on a 30-bed acute psychiatric unit of a general hospital. The i…](https://mymerci.kr/pages/nclex_q.php?qn_id=630057)
- [Situation: A 64-year-old man is in the intensive care unit (ICU) on day 2 after emergency …](https://mymerci.kr/pages/nclex_q.php?qn_id=630061)
- [Situation: A 64-year-old man is in the intensive care unit (ICU) on day 2 after emergency …](https://mymerci.kr/pages/nclex_q.php?qn_id=630062)
- [Situation: The nurse is a staff nurse on an inpatient psychiatric unit. The unit team of p…](https://mymerci.kr/pages/nclex_q.php?qn_id=630156)
- [Situation: The nurse is a staff nurse on an inpatient psychiatric unit. The unit team of p…](https://mymerci.kr/pages/nclex_q.php?qn_id=630157)
- [Situation: The nurse is a staff nurse on an inpatient psychiatric unit. The unit team of p…](https://mymerci.kr/pages/nclex_q.php?qn_id=630158)
- [Situation: A 34-year-old man is admitted to the intensive care unit (ICU) after an intenti…](https://mymerci.kr/pages/nclex_q.php?qn_id=630159)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._