NSG 3130 Exam 1
Study online at https://quizlet.com/_c3pv2h
1. General delega- -Always be familiar with your state board rules and regulations for delegation.
tion rules to follow -Refer to you facility policies and procedures for roles and responsibilities for
for the RN: task delegation.
-NEVER assume! Always ensure those you are delegating to (RN, LVN/LPN
and/or UAP) have the training and skill set to complete the task delegated to
them.
-Always validate! If you are unsure if a staff member does not have the knowledge
or skills to complete a task, ask them to demonstrate by stating "Please show me
how you would do this".
2. UAP Delegation: -Setting bed alarms, VS.
-Check patient status as directed by the RN- must report findings to the RN ("are
you still having pain?").
-Emptying drainage devices (indwelling urinary cats, suprapubic caths, JP drains,
etc).
-Record meals/routines.
-Typically UAPs do not care for chest tubes (even drainage). UAPs cannot give
medication.
3. LVN/LPN Delega- -Dressing changes.
tions: -Apply O2.
-Give PO, IM, SQ medications.
-Enemas.
-Urinary catheter insertion.
-Can care for stable patients that are not complex.
-No IVs or IV medications.
4. As the RN -Assessments/ reassessments.
you MUST com- -Evaluation (think nursing process).
plete the following -Education/teaching.
items, they cannot -Transfers (on or off the unit-they will need an assessment).
be delegated: -Post mortem care.
, NSG 3130 Exam 1
Study online at https://quizlet.com/_c3pv2h
-Abnormal results.
-Plan of care development.
-Going to or coming from surgery (includes pre op check lists and initial post
op assessment).
5. Things to remem- -Always remember, as an RN, you will also be delegated too- this means the first
ber as an RN dele- step when a patient assignment or task is delegated to YOU is to figure out what
gating: is needed or required.
-If there are patients/tasks you do not have the knowledge or skill set to care for
or complete, report to your charge nurse.
6. Documentation -Timely.
must be: -Accurate.
-Complete.
-Factual.
-NO slang or bias language-factual and objective.
-ALL CHARTING IS CONSIDERED LEGAL DOCUMENTATION.
7. Documentation -You can't look up a patient that you had the day before (HIPAA violation).
Standards: -If you are the interviewing nurse, you can access client's chart.
-You can document meds on the patient you gave meds to: do not document
medications or tasks you did not complete.
-Only need a section witness on required meds.
-You can discuss care of a client with the nurse that is precepting you.
8. Rules and Regula- -Ethical and Legal Concerns.
tions with Docu- -Confidentiality of all patient information.
mentation: -HIPAA updated April 14, 2003.
-Ensuring confidentiality of computer records.
9. Source-oriented: Each profession has a separate section of the record in which to do narrative
charting.
Study online at https://quizlet.com/_c3pv2h
1. General delega- -Always be familiar with your state board rules and regulations for delegation.
tion rules to follow -Refer to you facility policies and procedures for roles and responsibilities for
for the RN: task delegation.
-NEVER assume! Always ensure those you are delegating to (RN, LVN/LPN
and/or UAP) have the training and skill set to complete the task delegated to
them.
-Always validate! If you are unsure if a staff member does not have the knowledge
or skills to complete a task, ask them to demonstrate by stating "Please show me
how you would do this".
2. UAP Delegation: -Setting bed alarms, VS.
-Check patient status as directed by the RN- must report findings to the RN ("are
you still having pain?").
-Emptying drainage devices (indwelling urinary cats, suprapubic caths, JP drains,
etc).
-Record meals/routines.
-Typically UAPs do not care for chest tubes (even drainage). UAPs cannot give
medication.
3. LVN/LPN Delega- -Dressing changes.
tions: -Apply O2.
-Give PO, IM, SQ medications.
-Enemas.
-Urinary catheter insertion.
-Can care for stable patients that are not complex.
-No IVs or IV medications.
4. As the RN -Assessments/ reassessments.
you MUST com- -Evaluation (think nursing process).
plete the following -Education/teaching.
items, they cannot -Transfers (on or off the unit-they will need an assessment).
be delegated: -Post mortem care.
, NSG 3130 Exam 1
Study online at https://quizlet.com/_c3pv2h
-Abnormal results.
-Plan of care development.
-Going to or coming from surgery (includes pre op check lists and initial post
op assessment).
5. Things to remem- -Always remember, as an RN, you will also be delegated too- this means the first
ber as an RN dele- step when a patient assignment or task is delegated to YOU is to figure out what
gating: is needed or required.
-If there are patients/tasks you do not have the knowledge or skill set to care for
or complete, report to your charge nurse.
6. Documentation -Timely.
must be: -Accurate.
-Complete.
-Factual.
-NO slang or bias language-factual and objective.
-ALL CHARTING IS CONSIDERED LEGAL DOCUMENTATION.
7. Documentation -You can't look up a patient that you had the day before (HIPAA violation).
Standards: -If you are the interviewing nurse, you can access client's chart.
-You can document meds on the patient you gave meds to: do not document
medications or tasks you did not complete.
-Only need a section witness on required meds.
-You can discuss care of a client with the nurse that is precepting you.
8. Rules and Regula- -Ethical and Legal Concerns.
tions with Docu- -Confidentiality of all patient information.
mentation: -HIPAA updated April 14, 2003.
-Ensuring confidentiality of computer records.
9. Source-oriented: Each profession has a separate section of the record in which to do narrative
charting.