A nurse enters a client's room and sees a small fire in the client's bathroom.

Identify the sequence of steps the nurse should take.

(Move the steps, placing them in the order of performance. Use all the steps.)

The correct answer is B.

Choice A reason: Checking the client’s condition after the procedure involves assessment, which is a critical component of the nursing process. This task requires clinical judgment and knowledge of potential complications, which are responsibilities that cannot be delegated to assistive personnel.

Choice B reason: Assisting with ambulation is a task that can be safely delegated to assistive personnel. It is a basic care task that does not require clinical judgment and can be performed under the supervision of a nurse.

Choice C reason: Witnessing a client’s signature on the consent for the procedure is a legal and ethical responsibility that involves ensuring the client understands the procedure and is giving informed consent. This task requires a level of professional accountability that is beyond the scope of assistive personnel.

Choice D reason: Administering medication, such as atropine 30 minutes before the procedure, is a nursing intervention that requires knowledge of pharmacology and the ability to monitor for adverse effects. This is not within the scope of practice for assistive personnel and must be performed by licensed nursing staff.

Choice A rationale:

Metallic taste in mouth. Metallic taste in the mouth is a common side effect of many medications, including sertraline. It occurs due to the medication's effect on taste receptors. Patients should be informed about this side effect, but it is not a serious adverse effect that requires immediate medical attention.

Choice B rationale:

Increased urinary frequency. Increased urinary frequency is not a commonly reported side effect of sertraline. While some individuals may experience changes in urination patterns, it is not a significant adverse effect associated with this medication.

Choice C rationale:

Dry cough. Dry cough is not a known side effect of sertraline. Cough can occur due to various reasons, such as allergies, respiratory infections, or other medications, but it is not directly caused by sertraline.

Choice D rationale:

Excessive sweating. Excessive sweating, also known as hyperhidrosis, is a potential adverse effect of sertraline. It can be bothersome for some individuals and may impact their quality of life. Patients should be aware of this side effect and report it to their healthcare provider if it becomes bothersome or persistent.