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

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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About this topic: Delegation and Supervision

Delegation and supervision questions cover what an LPN/LVN may delegate to assistive personnel, what must stay with the nurse, and how to supervise and follow up on delegated tasks. This is one of 8 PN: Coordinated Care questions on delegation and supervision, each with a full explanation on a single study page.

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