The nurse is caring for a client in soft wrist restraints. Which tasks can the nurse safely delegate to the unlicensed assistive personnel? Select all that apply.

Question

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Delegating care to unlicensed assistive personnel (UAP) requires understanding of both body policies and staff member training. UAP may assist with care of stable clients related to tasks of basic hygiene (eg, bathing, toileting) and daily living (eg, feeding, positioning, range-of-motion exercises); measurement and documentation of vital signs and intake and output; and technical skills (eg, capillary blood glucose monitoring, IV catheter removal) with appropriate training (Options A, D, and E). Assurance of appropriateness and completion of delegated tasks remain the duty of the nurse. (Options B and C) When physical restraints are applied to a client, the nurse is responsible for the primary and ongoing assessments (eg, skin integrity, peripheral pulses, neurovascular status), determining appropriateness of restraint type, need for continued use, and psychological response. These tasks may not be delegated to the UAP. The UAP may report changes in these areas if noted but must not be expected to monitor for changes. Educational objective: Nurses may delegate to unlicensed assistive personnel tasks that relate to basic hygiene; tasks of daily living; measurement and documentation of vital signs and intake and output; and validated technical skills. Activities requiring assessment may be performed only by the nurse.

The Nurse Is Caring for a Client in Soft Wrist