The unlicensed assistive personnel (UAP) notifies the charge nurse that the client told the UAP that the client is feeling short of breath. What should the charge nurse do first?

Question

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When a registered nurse (RN) receives a report of a client complaint that is potentially ominous from a staff member of lesser qualifications, the RN should personally assess the client. This is the primary nursing assessment that will be used to decide if an urgent need exists and a change in the nursing plan of care is needed. (Option A) It is important to assess the client prior to acting (the nursing process) on initiating a rapid response team based on a report from a staff member with less knowledge and skills. The nurse may not find an acute client need during the assessment. (Option B) The UAP could be asked to go with the RN and obtain vital signs as the RN is assessing the client, but the UAP should not be asked to independently obtain this assessment first. (Option C) The RN should assess the client personally rather than assign the task to the LPN. LPNs are assigned clients who are basically stable. The RN should be involved when there is new-onset potential instability in a client's condition. Educational objective: The nurse must assess the client personally (rather than delegating) when a potentially ominous report is made by a less-qualified staff member.

The Unlicensed Assistive Personnel (UAP) Notifies the Charge Nurse That