A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology?

The correct answer is: B.

Choice A reason:

Suctioning a client's long-term tracheostomy is a complex procedure that involves sterile technique and assessment skills that are beyond the scope of assistive personnel's practice. It requires clinical judgment and the ability to respond to complications, which are responsibilities typically reserved for licensed nursing staff.

Choice B reason:

Using a pain rating scale to monitor a client's pain level is a task that can be delegated to assistive personnel. It involves asking the client to rate their pain on a scale, which does not require clinical judgment or advanced skills. The assistive personnel can then report the pain level to the nurse, who will make decisions regarding pain management.

Choice C reason:

Performing a dressing change on a client's peripherally inserted central catheter (PICC) is not within the scope of assistive personnel. This task requires aseptic technique and knowledge of PICC line management to prevent infection and other complications, which are typically the responsibility of the registered nurse or licensed practical nurse.

Choice D reason:

Instructing a client on self-administration of a tap water enema involves teaching and assessment to ensure the client understands and can perform the procedure safely. This is a task that requires licensed nursing knowledge and skills to educate the client and evaluate their competency.

Choice A reason: Closing the fire doors and the doors to the clients' rooms is an action that the nurse should take after activating the fire alarm, as it helps to contain the fire and prevent smoke inhalation.

Choice B reason: Activating the fire alarm is the first action that the nurse should take after removing the client from the room, as it alerts the fire department and the rest of the staff and clients about the fire.

Choice C reason: Extinguishing the fire is an action that the nurse should take only if the fire is small and confined, and after activating the fire alarm and ensuring the safety of the client and self. The nurse should use the appropriate fire extinguisher and follow the PASS technique (pull, aim, squeeze, sweep).

Choice D reason: Removing all clients from the unit is an action that the nurse should take only if the fire is large and spreading, and after activating the fire alarm and ensuring the safety of the client and self. The nurse should follow the RACE protocol (rescue, alarm, confine, extinguish/evacuate) and the facility's emergency plan.