A nurse in an outpatient clinic is assessing a client who is pregnant for unsafe behaviors during pregnancy. Which of the following findings indicates a need for further evaluation?

Rationale:

A. A client who has dementia and is incontinent of urine: This client has multiple contributing factors, cognitive impairment limits repositioning and self-care, while urinary incontinence increases skin moisture and maceration, promoting skin breakdown and pressure injury formation.

B. A client who is 2 days postoperative following orthopedic surgery: Although this client may have limited mobility, they are typically on a monitored recovery path with interventions like repositioning, early ambulation, and pain management, reducing their overall risk.

C. A client who has a T-tube following an open cholecystectomy: This client is generally alert, mobile with assistance, and able to communicate needs, which lowers their risk of pressure injury compared to more dependent individuals.

D. A client who has had a recent myocardial infarction: This client may be monitored in bed rest initially, but cardiovascular stability and mobility often improve quickly with treatment, making their pressure injury risk moderate rather than the highest among the group.

Rationale:

A. Ask an experienced nurse to assist with the procedure: Seeking guidance from an experienced nurse supports safe practice and skill development. It ensures the procedure is performed correctly while providing an opportunity for supervised learning, which is appropriate for a newly licensed nurse.

B. Delegate the task to an assistive personnel: Tracheal suctioning is a sterile and invasive procedure that requires the clinical judgment and skills of a registered nurse. It should not be delegated to assistive personnel who are not trained or licensed to perform such procedures.

C. Refuse to take the assignment: Refusing the assignment without attempting to seek help or learn is not a constructive or professional approach. Nurses are expected to seek support when performing unfamiliar but appropriate tasks within their role.

D. Identify that the task is in the scope of RN practice and perform the suctioning: While it is within the RN scope, performing a skill without training or supervision may compromise patient safety. Competence must be demonstrated or developed with supervision before performing independently.