The nurse is caring for a mechanically ventilated client with a tracheostomy tube in the intensive care unit. What client care tasks can the nurse safely delegate to the unlicensed assistive personnel? Select all that apply.

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Clients requiring mechanical ventilation receive care from many members of the health care team. Nurses must often delegate tasks to ensure that care is provided in a timely manner. When delegating, nurses must consider the stability of the client and the experience level of unlicensed assistive personnel (UAP). In accordance with the five rights of delegation, nurses may delegate the following client care tasks to the UAP: Performing routine oral care, which will not affect medical stability in a client with a tracheostomy tube (Option A) Measuring and obtaining vital signs (Option D) Testing blood glucose (per hospital policy) Performing personal hygiene and skin care (eg, bathing) Performing passive and/or active range-of-motion exercises (Option E) Measuring output (eg, urinary, drainage) (Option B) The tracheostomy is a surgically created airway with a high risk of infection. Only licensed individuals (eg, registered nurse, licensed practical nurse) should perform tracheostomy care. (Option C) Although an elevated head of bed (HOB) is necessary to prevent ventilator-acquired pneumonia and improve chest expansion, teaching is not within the scope of the UAP and should be performed only by nurses. However, after nurses provide teaching, the UAP may remind the family to keep the HOB elevated. Educational objective: When caring for a ventilated client, nurses may consider delegating the following tasks to unlicensed assistive personnel: vital sign measurement, oral care, personal hygiene, blood glucose testing, passive or active range-of-motion exercises, and measurement of urine and drainage output.

The Nurse Is Caring for a Mechanically Ventilated Client with a Tracheostomy