護理師準備分派工作給照護輔助人員（UAP）。下列哪項任務適當？
A nurse is preparing to delegate tasks to an unlicensed assistive personnel (UAP). Which task is appropriate to delegate?
- AAssisting with ambulation of a stable client協助穩定的病人步行正確答案
- BAssessing the client's skin turgor評估病人的皮膚彈性
- CFeeding a client who has dysphagia餵食有吞嚥障礙的病人
- DEvaluating whether the client's pain has decreased after receiving an analgesic評值病人在接受止痛藥後疼痛是否減輕
- A協助穩定的病人步行
依 NCSBN 與 ANA 的全國性分派指引，護理判斷、臨床推理與關鍵決策不可分派；護理過程中的評估（assessment）、計畫（planning）、評值（evaluation）與病人教育，都屬於 RN 的專業範疇，同樣不可分派給輔助人員。可以分派的是常規、結果可預期、且病人狀況穩定的工作。 A 為正解：協助狀況穩定的病人下床活動屬於標準輔助照護，同時滿足分派五項正確中的「正確任務」與「正確情境（病人狀況穩定）」。 B 錯誤：評估皮膚彈性是評估行為，需要護理判斷來解讀脫水程度與皮膚狀況。 C 錯誤：吞嚥困難病人的餵食帶有明確的吸入風險，結果不可預期，須由護理人員執行或全程在旁監督。 D 錯誤：判斷「給藥後疼痛是否減輕」屬於評值，是護理過程的一環，不可分派——輔助人員可以轉述病人說了什麼，但對治療反應的判讀與後續處置決定必須由護理師做。 提醒：即使工作分派出去，護理師對病人整體照護結果仍負最終當責，當責不可轉移。
- A · 正確答案協助穩定的病人步行
協助穩定病人下床活動屬於 UAP 之標準業務範圍，符合安全規範。
- B評估病人的皮膚彈性
評估皮膚彈性為護理師的臨床評估範疇，不可由 UAP 執行。
- C餵食有吞嚥障礙的病人
吞嚥障礙病人有高吸入風險，餵食需由具備評估能力的護理人員執行。
- D評值病人在接受止痛藥後疼痛是否減輕
涉及侵入性管路之尿量測量，在許多機構需由護理師監控，以防感染。
台灣照服員（看護）權限較美國 UAP 更廣，但在法規層面，護理師對受權責仍保持高度監督責任。實際要求可能受聯邦法、州法、州護理委員會規則與機構政策影響；本題依題幹所示護理原則作答。
English explanation
Option A is correct because assisting a stable client with ambulation is routine supportive care with a predictable outcome and meets the rights of the correct task and correct circumstance. National delegation guidance reserves nursing judgment, clinical reasoning, critical decisions, assessment, planning, evaluation, and client education for the registered nurse. Option B is incorrect because assessing skin turgor requires nursing judgment to interpret hydration and skin condition. Option C is incorrect because feeding a client with dysphagia carries a clear aspiration risk and an unpredictable outcome, so a nurse must perform it or remain present throughout. Option D is incorrect because determining whether pain decreased after an analgesic is evaluation within the nursing process. Assistive personnel may report the client's words, but the nurse must interpret the treatment response and decide subsequent care. Even after delegation, the registered nurse retains final accountability for the client's overall care outcomes; accountability cannot be transferred.
最近修訂：2026-10-06