🟨 Urine output <30 mL/hr suggests impaired perfusion or acute kidney injury.

🟨 This is a postoperative complication requiring immediate intervention.

🟨 Low output can indicate hypovolemia, hemorrhage, or renal failure.

🟨 Early recognition prevents progression to shock.

🟨 This is the only finding that reflects actual physiological instability.

Blood transfusion BP 138/76

🟨 BP is stable.

🟨 No sign of transfusion reaction.

Dementia and oriented to person

🟨 Baseline for many dementia patients.

🟨 Not an acute change.

Traction pain 4/10

🟨 Mild pain is expected.

🟨 Stable finding, not priority.

🟪 The nurse must evaluate whether the delegated task achieved desired outcomes.

🟪 Evaluation maintains accountability, which the nurse never relinquishes.

🟪 It ensures the task was performed safely and effectively.

🟪 Outcome review identifies opportunities for feedback or correction.

🟪 This aligns with the 5 rights of delegation.

Nurse gives up accountability

🟪 The nurse maintains full accountability for all delegated care.

🟪 Incorrect principle.

A delegated task does not require predictable outcomes

🟪 Delegation requires predictable outcomes for safety.

🟪 Unpredictable results must remain with the RN.

AP should document the client’s outcome

🟪 The AP documents task completion, not outcome evaluation.

🟪 Evaluation is the nurse’s responsibility.

🟫 This response respects the client’s cultural, religious, or personal preferences.

🟫 It avoids confrontation and maintains therapeutic rapport.

🟫 Offering accommodation supports client-centered care.

🟫 It demonstrates respect for modesty and privacy needs.

🟫 The nurse provides a solution rather than questioning or dismissing the concern.

Notify the charge nurse

🟫 Escalation is unnecessary before attempting reasonable accommodation.

🟫 The nurse can address the request directly.

AP is very capable

🟫 This dismisses the client's comfort.

🟫 Not patient-centered.

Why don’t you want

🟫 Confrontational and intrusive.

🟫 Not therapeutic communication.

🟦 A complete list of current medications is essential for continuity of care during transfer to rehabilitation.

🟦 Medication reconciliation helps prevent omissions, duplications, or medication errors at the receiving facility.

🟦 It ensures the rehabilitation team maintains correct dosing of anticoagulants, pain medications, and chronic therapies, which are critical after a hip replacement.

🟦 Knowing all medications allows the next team to safely modify treatment based on labs, mobility status, and comorbidities.

🟦 This information is a required element of safe hand-off communication during facility transfers.

Vital signs for the past 72 hr

🟦 Only current or recent vital signs are generally needed; 72-hour history is unnecessary and excessive.

🟦 It does not improve safety as much as essential clinical information like medications.

Last bath given

🟦 Bath time is not clinically relevant for transfer decisions.

🟦 Rehabilitation facilities focus on medical stability and treatment needs, not hygiene timing.

Admission paperwork

🟦 Admission documentation stays in the original facility; it is not part of required handover information.

🟦 Transfer requires current clinical data, not administrative intake forms.

🟩 During a disaster, nurses prioritize triage and life-saving interventions, because resources and time are limited.

🟩 This action aligns with disaster protocols that classify clients based on the severity of their condition.

🟩 The goal is to stabilize individuals at greatest risk of death or rapid deterioration.

🟩 Nurses focus on airway, breathing, circulation, and controlling bleeding to prevent avoidable fatalities.

🟩 This responsibility reflects the nurse’s central role in disaster response and emergency management.

Reinforce discharge teaching to clients

🟩 Teaching is not a priority during disaster response and diverts attention from life-saving needs.

🟩 Education can occur later when the emergency phase is resolved.

Instruct the AP to focus on clients’ ADLs

🟩 ADLs are low-priority during disaster conditions.

🟩 Resources must be directed toward clients with life-threatening conditions.

Stock additional unit supplies

🟩 Supply preparation is part of disaster planning, not the nurse’s priority during active disasterresponse.

🟩 The immediate role is triage and clinical care, not logistics.

🟦 A confused surgical client with multiple tubes (e.g., drains, IV lines, catheters) requires continuous clinical assessment, which is outside the AP’s scope.

🟦 Observation in this case is not simple “sitting,” but involves monitoring for tube dislodgement, bleeding, respiratory changes, and altered mental status, all requiring nursing judgment.

🟦 Only licensed nurses can safely evaluate changes in behavior or deterioration in clients with postoperative complications.

🟦 Delegating this increases risk of accidental removal of lines or drains, which can be life-threatening.

🟦 This client requires professional monitoring because confusion places them in the high-risk category for injury.

Assist a client to eat who has difficulty seeing the foods on the tray

🟦 This is an appropriate AP task because it involves basic feeding assistance, not clinical assessment.

🟦 Visual impairment does not require licensed nursing judgment.

Provide postmortem care for a client who has died

🟦 APs are routinely trained to perform postmortem care under nurse direction.

🟦 This task is standardized, predictable, and within AP scope.

Deliver a client's urine specimen to the laboratory

🟦 Transporting specimens is a non-clinical task appropriate for APs.

🟦 This task does not require assessment or decision-making

🟦 Before delegating any activity, the nurse must confirm that the task is within the AP’s job description, scope of practice, and facility policy.

🟦 Delegating tasks outside this scope places the client at risk and violates legal and professional standards.

🟦 Ensuring scope alignment allows the nurse to delegate safely while retaining accountability for outcomes.

🟦 This determination supports proper delegation following the Five Rights of Delegation, specifically the Right Task.

🟦 Knowing what APs are permitted to do prevents unsafe assignments and ensures appropriate use of team members.

The AP's ability to prioritize

🟦 APs are not responsible for independent clinical prioritization; that is the nurse’s role.

🟦 Delegation is based on the nurse’s priorities—not the AP’s.

The AP's rapport with the client

🟦 Rapport is helpful but not required for safe delegation.

🟦 Delegation must be based on competency and scope, not personality.

Whether the nurse can more efficiently and effectively complete the task

🟦 Delegation is not about efficiency—it’s about safe distribution of workload.

🟦 Even if the nurse can do it faster, the task may still be appropriate to delegate.

🟦 A democratic leadership style actively seeks team input, feedback, and shared decision-making, making it ideal for an in-service requiring participation.

🟦 It empowers staff to contribute ideas for reducing nosocomial infections, which increases engagement and ownership.

🟦 This style encourages collaboration, open discussion, and mutual problem solving among team members.

🟦 It improves motivation and teamwork by valuing each individual’s experience and perspective.

🟦 Democratic leadership is most effective when the goal is collective improvement and innovation.

Open-door

🟦 Open-door policy refers to communication approach, not a leadership style.

🟦 It does not inherently promote structured group participation.

Laissez-faire

🟦 This style offers minimal direction and often results in low productivity and poor coordination.

🟦 It is inappropriate when structured feedback and active involvement are needed.

Autocratic

🟦 Autocratic leaders make decisions without group input, which discourages participation.

🟦 This style suppresses feedback and is ineffective for brainstorming.