Question

The unlicensed assistive personnel (UAP) reports to the staff nurse that a client who had surgery 4 hours ago has a decrease in blood pressure (BP), from 150/80 to 110/70, in the past hour. The nurse advises the UAP to check the client's dressings for excess drainage and report the findings to the nurse. Which factor is most important to consider when assessing the legal ramifications of this situation?

A. The parameters of the state's or province's nurse practice act
B. The need to complete an adverse occurrence report
C. Hospital protocol regarding the frequency of vital sign assessment every hour postoperatively
D. The healthcare provider's prescription for changing the postoperative dressing

Answer 1

The legal implications in this case revolve around proper delegation and adherence to the healthcare provider's prescriptions for postoperative care, including the monitoring of dressings and reporting significant changes in blood pressure.

Step-by-step explanation:

The most important factor to consider when assessing the legal ramifications of a client's decrease in blood pressure after surgery involves understanding the delegation of tasks in accordance with the healthcare provider's prescription and adhering to the scope of practice and standards of care. The staff nurse's instruction for the Unlicensed Assistive Personnel (UAP) to check the client's dressings for excess drainage and report the findings is critical because it aligns with the legal requirement that tasks must be delegated under the supervision and direction of a licensed professional, such as the staff nurse, who carries the responsibility for patient care.

Furthermore, another essential aspect is whether the UAP has been properly trained and is competent to perform the specific task of checking dressings for signs of excess bleeding, which could indicate postoperative complications. The nurse must ensure that the delegation of duties is within the UAP's abilities and that the UAP understands the urgency of reporting back, especially following a significant change in a vital sign like blood pressure. The healthcare provider's prescription for changing the postoperative dressing will also guide how often and under what circumstances dressings should be assessed or changed.