Delegation
The RN asks a UAP to measure and document intake and output for a stable patient. This delegation right is being met because the activity is routine and has a predictable outcome.
What is the right task?
“I am calling about Ms. Evans because she developed sudden shortness of breath and her oxygen saturation is 84%.” This portion of SBAR identifies the immediate problem.
What is Situation?
This area around the outside edge of an opened sterile field is considered contaminated.
What is the outer 1-inch border?
A patient says, “You know who I am,” before medication administration. The nurse must still complete this safety action.
What is verify the patient using two approved identifiers?
Thirty minutes after receiving insulin, a patient becomes shaky, sweaty, hungry, and irritable. This is the nurse’s first assessment.
What is immediately check the patient’s blood glucose level?
A UAP reports that a previously stable patient’s blood pressure is 82/46 mm Hg. This is the RN’s priority action.
What is immediately assess the patient and initiate appropriate nursing interventions?
“Her respiratory rate is 32, bilateral crackles are present, and I believe her respiratory condition is worsening.” This statement represents this SBAR component.
What is Assessment?
A nurse lowers a sterile instrument below waist level and then returns it to the field. This is the correct response.
What is discard the instrument because it is contaminated?
A patient cannot follow directions, cannot bear weight safely, and is unpredictable during movement. This is the safest transfer method.
What is use an appropriate mechanical lift with trained assistance?
Insulin doses are measured using this unit rather than milliliters.
What are units?
What are the 5 rights of delegation
“She was admitted yesterday with pneumonia and has been receiving oxygen at 2 L/min.” This information belongs in this part of SBAR.
What is Background?
Sterile solution soaks through the sterile drape to the nonsterile bedside table beneath it. This type of contamination has occurred.
What is strike-through contamination?
After collecting a blood specimen, the nurse should label the tube at this location and time.
What is at the bedside, immediately after collection and in the patient’s presence?
Even when a patient has no symptoms, a blood glucose below this value is considered hypoglycemia.
What is 70 mg/dL?
The RN tells the UAP, “Walk Mr. Jones sometime today,” without explaining the distance, assistance needed, precautions, or findings to report. This right is missing.
What is the right direction and communication?
After reporting a patient’s decreasing level of consciousness, the nurse should conclude the SBAR communication with this type of specific statement.
What is a Recommendation or Request, such as asking the provider to evaluate the patient immediately?
A nurse’s sterile glove touches the IV pole and then touches sterile gauze on the field. These items must now be replaced.
What are the contaminated glove and the gauze it touched?
A patient’s blood pressure changes from 138/76 lying down to 112/62 after standing, and the patient reports dizziness. The nurse recognizes this condition.
What is orthostatic hypotension?
A patient asks for a chocolate bar to treat hypoglycemia. Juice or glucose tablets are preferred because this nutrient in chocolate delays glucose absorption.
What is fat?
A UAP fails to report a urine output of 20 mL over four hours. These two healthcare workers have separate accountability for the delegation process.
Who are the UAP, who is accountable for performing and reporting the task, and the RN, who is accountable for supervision and evaluation?
The provider responds to an SBAR report with several new verbal orders. To close the communication loop and verify accuracy, the nurse should perform this action.
What is repeat back the orders and receive confirmation?
The nurse is uncertain whether a sterile instrument touched the contaminated border of the field. This principle determines the nurse’s response.
What is “when sterility is in doubt, consider the item contaminated”?
The nurse finds a patient on the floor after an unwitnessed fall. This must occur before attempting to return the patient to bed.
What is assess the patient for injuries and neurological changes, obtain assistance, and follow the facility’s post-fall protocol?
A patient becomes unconscious during a hypoglycemic episode. Giving juice by mouth would place the patient at greatest risk for this complication.
What is aspiration?