護理師正在規劃一群病人的照護計畫。下列哪項任務應委派給非執照輔助人員(UAP)?
A nurse is planning care for a group of clients. Which task should the nurse delegate to an unlicensed assistive personnel (UAP)?
- AMeasuring the intake and output of a client with congestive heart failure✓ 正解測量充血性心臟衰竭病人的出入量
- BAssessing the skin integrity of a client with a new stage 2 pressure injury評估患有新發第二期壓瘡病人的皮膚完整性
- CEvaluating the effectiveness of pain medication for a postoperative client評估止痛藥對術後病人的療效
- DProviding discharge instructions to a client after a cardiac catheterization提供心臟導管術後病人的出院衛教
委派的核心原則是將「非侵入性、常規性、不涉及臨床判斷」的任務交給 UAP。紀錄攝入與排出量(I/O)是一項標準化的技能,不需要專業的護理評估或診斷。護理師在委派時應遵循五大權利(Five Rights of Delegation):正確的任務、正確的情況、正確的人員、正確的指導與溝通、正確的監督與評估。雖然 UAP 收集了數據,但最終對數據的詮釋(例如:尿量減少是否代表腎衰竭)仍是護理師的責任。此題測試的是對護理範疇與委派界限的理解,確保專業護理資源能集中在需要評估與教學的病人身上。
Measuring intake and output is a standardized, non-invasive task that does not require clinical judgment, making it appropriate for delegation to unlicensed assistive personnel. Assessment, evaluation of medication effectiveness, and patient teaching are professional nursing responsibilities that must remain with the registered nurse.
在美國,UAP(如 CNA)的職責界定非常明確,且有專屬的認證制度,護理師需負起委派後的監督法律責任;在台灣,類似角色為病房助理或看護,其執業範圍較缺乏全國統一法源,多依各醫院內規執行,且家屬聘請的私籍看護不屬於醫院組織體系,委派時更需注意風險。