# Situation: The adult medical-surgical ward of a 150-bed provincial hospital has 28 clients on the day shift. The charge nurse works with three staff nurses and two nursing attendants. The nursing attendants are unlicensed workers trained through a health care services program and the hospital's orientation. A staff nurse asks a nursing attendant to help monitor a stable client whose antihypertensive dose was increased today. Which instruction BEST meets the right direction and communication of delegation?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630355  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: The adult medical-surgical ward of a 150-bed provincial hospital has 28 clients on the day shift. The charge nurse works with three staff nurses and two nursing attendants. The nursing attendants are unlicensed workers trained through a health care services program and the hospital's orientation.

A staff nurse asks a nursing attendant to help monitor a stable client whose antihypertensive dose was increased today. Which instruction BEST meets the right direction and communication of delegation?

## 보기

1. Take the vital signs of the client in bed 12 every 4 hours and chart any values that look abnormal.
2. Take bed 12's blood pressure at 10:00 and 14:00; report a systolic below 90 mmHg at once. **✔ 정답**
3. Take the vital signs of all the clients in my group before lunch and write them on the sheet.
4. Please look in on the client in bed 12 this morning and let me know later how the client is doing.

**정답: 2**

## 해설

Clear direction names the client, the task, the times, and the specific values that must be reported and when. Asking the worker to judge what is abnormal or to 'look in on' a client hands over assessment, which stays with the registered nurse.

## 심화 해설

Clear direction and communication
Effective delegation follows the five rights: right task, right circumstance, right person, right direction and communication, and right supervision and evaluation. Clear direction names the client, the task, the times, and the specific values that must be reported and when. "Take bed 12's blood pressure at 10:00 and 14:00; report a systolic below 90 mmHg at once" gives the attendant everything needed and keeps interpretation with the nurse.

Why specific reporting limits matter
The client is stable, but his antihypertensive dose was increased today, so the main risk is hypotension. Measuring blood pressure is a routine, standardized task with predictable results, which can be delegated to a trained nursing attendant. Deciding whether a value is abnormal and what it means is assessment, which stays with the registered nurse. By naming an exact threshold and saying "at once," the nurse turns judgment into a clear rule the attendant can follow and makes sure the nurse hears about a dangerous value immediately.

| Instruction | Problem or strength |
| --- | --- |
| Vital signs every 4 hours; chart values that look abnormal | The attendant decides what is abnormal; no report timing |
| BP at 10:00 and 14:00; report systolic below 90 mmHg at once | Correct: client, task, times, and exact reporting value |
| Vital signs of all clients before lunch | No reporting limits; no priority for the client whose dose changed |
| Look in on bed 12; tell me later how the client is doing | An assessment request with no task, time, or limit |

Common delegation errors
Watch out! Instructions that ask an unlicensed worker to "look in on" a client, to judge what "looks abnormal," or to report "how the client is doing" quietly hand over assessment, which cannot be delegated. They also give no time frame, so an abnormal value might be charted but not reported until it is too late. Group instructions such as "all the clients in my group" fail to highlight the client at highest risk.

Supervision after delegating
The nurse remains accountable for the outcome. After delegating, the nurse checks that the attendant understood, for example by asking for a read-back, follows up at the stated times, reviews the recorded values, and personally assesses the client if any value is near the limit or if the client reports dizziness. Delegation does not end responsibility; it shares the work under the nurse's supervision.

Exam takeaway
Key point! The best delegation instruction states the who, what, when, and what to report with exact values and timing. Avoid any instruction that asks an unlicensed worker to interpret findings.

## 임상 시나리오

Right Direction in DelegationGiving a nursing attendant clear instructions
Clear direction names the client, the task, the times, and the exact values to report: "Bed 12's BP at 10:00 and 14:00; report a systolic below 90 mmHg at once."

Measuring blood pressure can be delegated; deciding what is abnormal is assessment and stays with the registered nurse.

After delegating, confirm understanding, follow up at the stated times, and review the results. The nurse remains accountable.

CautionInstructions such as "look in on" a client or "chart anything abnormal" hand over assessment and give no reporting limits or timing.

## 핵심 개념

- **Delegation** — Assigning a task to another person while the nurse keeps accountability for the outcome.
- **Five rights of delegation** — Right task, circumstance, person, direction and communication, and supervision and evaluation.
- **Nursing attendant** — An unlicensed worker who performs routine care tasks under a nurse's direction.
- **Reporting parameter** — A specific value or change that must be reported to the nurse, with a time frame.
- **Accountability** — The nurse's responsibility for the outcomes of care, including delegated tasks.

## 같은 주제 문제

- [Situation: The adult medical-surgical ward of a 150-bed provincial hospital has 28 clients…](https://mymerci.kr/pages/nclex_q.php?qn_id=630351)
- [Situation: The adult medical-surgical ward of a 150-bed provincial hospital has 28 clients…](https://mymerci.kr/pages/nclex_q.php?qn_id=630352)
- [Situation: The adult medical-surgical ward of a 150-bed provincial hospital has 28 clients…](https://mymerci.kr/pages/nclex_q.php?qn_id=630353)
- [Situation: The adult medical-surgical ward of a 150-bed provincial hospital has 28 clients…](https://mymerci.kr/pages/nclex_q.php?qn_id=630354)
- [Situation: A 30-bed adult medical ward admits many clients with diabetes, liver disease, a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630451)
- [Situation: A 30-bed adult medical ward admits many clients with diabetes, liver disease, a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630452)
- [Situation: A 30-bed adult medical ward admits many clients with diabetes, liver disease, a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630453)
- [Situation: A 30-bed adult medical ward admits many clients with diabetes, liver disease, a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630454)

---

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

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