A client who is terminally ill tells a nurse on the medical-surgical unit that she feels hopeless. Which of the following statements by the nurse is appropriate?

Rationale:

A. An infant who has pertussis and is receiving oxygen via nasal cannula requires immediate assessment to ensure that the oxygen therapy is adequate and to monitor for any signs of respiratory distress or worsening condition.

B. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions does not require immediate assessment as the client is stable enough for discharge planning.

C. A school-age child who has diabetes mellitus and requires blood glucose monitoring should be assessed, but it is less urgent compared to a client with a respiratory condition.

D. A toddler who has both arms in casts and needs to be fed his breakfast needs attention, but this is less critical compared to monitoring a client with a respiratory condition.

Rationale:

A. Palpate for possible bladder distention is a task that requires nursing assessment skills and should be done by the nurse.

B. Observe the incision site is a nursing task that involves assessing for signs of complications.

C. Change the abdominal dressing requires sterile technique and should be done by a nurse to prevent infection and ensure proper care.

D. Obtain vital signs is within the AP’s scope of practice and is a task that can be delegated. It is important for monitoring the client’s status and identifying potential issues.