RN 正在為內科病房四位病人的照護進行分工。下列哪些工作適合授權給無執照輔助人員（UAP）？（選所有適合的）
The RN is organizing care for a four-client assignment on a medical unit. Which actions are appropriate to delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- AObtaining a pulse oximetry reading to evaluate a client with asthma who reports sudden, severe shortness of breath.為一位主訴突然嚴重呼吸困難的氣喘病人測量血氧飽和度以進行評估。
- BFeeding a pureed diet to a client who had a stroke 3 days ago and has passed a bedside swallow evaluation.餵食一位三天前中風、已通過床邊吞嚥評估的病人泥狀飲食。正確答案
- CAmbulating a 70-year-old client down the hall for the first time, 12 hours after a total hip arthroplasty.協助一位全髖關節置換術後 12 小時的 70 歲病人首次沿走廊行走。
- DMeasuring vital signs and recording strict intake and output for a stable client receiving routine IV fluids.為一位接受常規靜脈輸液、病況穩定的病人測量生命徵象並嚴格記錄輸出入量。正確答案
- EApplying a prescribed over-the-counter hydrocortisone barrier cream to an older adult client's newly discovered, excoriated red sacral rash.為一位老年病人新發現、已有表皮破損的薦骨部紅疹，塗抹醫囑的非處方 hydrocortisone 隔離乳膏。
- B餵食一位三天前中風、已通過床邊吞嚥評估的病人泥狀飲食。
- D為一位接受常規靜脈輸液、病況穩定的病人測量生命徵象並嚴格記錄輸出入量。
本題測驗 UAP (無照護佐) 的精確任務授權。UAP 的交辦兩大黃金鐵律：1. 不涉及護理評估 (No assessments)。 2. 病患必須處於「慢性穩定 (Chronic stable)」狀態，絕不能是急性或具不可預期風險 (First-time / Acute instability) 的情況。選項 B 中，病患中風後已經通過了嚴格的吞嚥評估 (Passed swallow eval)，代表他目前進食沒有立即的噎住/吸入風險，這屬於基礎的日常生活活動 (ADL)，完美適合 UAP 餵食。選項 D 針對穩定的病患測量生命徵象與記錄 I/O，是 UAP 最標準的核心常規任務。選項 A 錯誤，這個氣喘病患出現了全新的急速呼吸困難，這是致命急性變化，必須由 RN 親自測量並評估血氧。選項 C 錯誤，任何手術後的『第一次 (first time)』下床活動，病患摔倒與昏厥的風險極高，必須由 RN 或物理治療師執行。選項 E 即使是成藥藥膏 (OTC cream)，給藥依然是 UAP 的絕對禁區，且全新發現的紅疹是由 RN 先行評估的。
- A為一位主訴突然嚴重呼吸困難的氣喘病人測量血氧飽和度以進行評估。
針對一名快速惡化且呼吸不穩之病患的生命徵象，被視為一項急性評估功能，唯獨需要直接的 RN 檢傷專業。
- B · 正確答案餵食一位三天前中風、已通過床邊吞嚥評估的病人泥狀飲食。
餵食一位已經過評估、確認放行且生理穩定的病患，嚴格符合了常規、具預期性之日常活動的定義。
- C協助一位全髖關節置換術後 12 小時的 70 歲病人首次沿走廊行走。
最初的手術後第一次下床活動，潛藏著極高風險的突發姿勢性昏厥生理危險，需要急性的 RN 監控。
- D · 正確答案為一位接受常規靜脈輸液、病況穩定的病人測量生命徵象並嚴格記錄輸出入量。
針對穩定住院病患定期記錄輸入、輸出與標準生命徵象，完美落在 UAP 的機械性職務範圍內。
- E為一位老年病人新發現、已有表皮破損的薦骨部紅疹，塗抹醫囑的非處方 hydrocortisone 隔離乳膏。
塗抹任何醫療藥膏本質上已構成給藥行為，在國家 UAP 規範中是被全盤禁止的。
授權護佐 (Delegation to UAP)：永遠記住不能包含「EAT」：Evaluate(評估)、Assess(觀察判斷)、Teach(衛教)。另外，任何程序的「第一次 (First time)」一律由護理師親自執行。
English explanation
Options B and D are correct. Option B is appropriate because the client has passed a swallow evaluation, indicating no immediate choking or aspiration risk, and feeding is a basic activity of daily living that can be assigned to unlicensed assistive personnel. Option D is appropriate because measuring vital signs and recording strict intake and output are routine tasks for a stable client receiving routine intravenous fluids. Option A is not selected because sudden, severe shortness of breath in a client with asthma is a new, potentially fatal acute change; the registered nurse must personally obtain and assess the oxygen saturation. Option C is not selected because the first ambulation after surgery carries high risks of falling and fainting and must be performed by the registered nurse or physical therapist. Option E is not selected because applying even an over-the-counter cream is medication administration, which cannot be delegated to unlicensed assistive personnel, and the newly discovered rash first requires registered nurse assessment.
最近修訂：2026-10-06