NCLEX · Delegation and Supervision

A UAP reports that a stable post-op client's vital signs are: BP 138/82, HR 88, RR 18, T 99.2°F. What should the LPN do?

Correct answer

Acknowledge the report, note the values are within expected range for this client, document, and continue monitoring per orders

  1. A Ignore the report
  2. B Acknowledge the report, note the values are within expected range for this client, document, and continue monitoring per orders
  3. C Have the UAP retake the vitals
  4. D Call the surgeon immediately

Why this is the answer

Effective delegation requires the nurse to receive, evaluate, and act on UAP reports. These vitals are within normal/expected ranges: BP 138/82 (slightly elevated but not concerning in immediate post-op), HR 88, RR 18, T 99.2°F (mild post-op temperature is common from inflammation, atelectasis, or surgical stress and is not concerning unless >100.4°F or with other symptoms). The LPN should: (1) Acknowledge the UAP's report — reinforces good communication; (2) Compare values to baseline, ordered parameters, and clinical context; (3) Document; (4) Continue per orders. Don't dismiss reports — UAPs need to feel heard. Don't escalate unnecessarily — but DO escalate when values are abnormal or trending poorly. Don't have UAP retake without a reason. Don't call physician for normal values. NCLEX delegation answers often test whether you appropriately respond to data from UAPs vs over-react or under-react.
Source: NCSBN NCLEX-PN, Supervising UAP

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