A nurse is assisting in the discharge planning of an infant who has a spica cast. Which of the following equipment needs should the nurse identify for discharge?

A. "If I have a health care proxy, then I do not need to have a living will.": A health care proxy and a living will serve different purposes. A living will outlines specific treatment preferences, while a health care proxy designates someone to make decisions. Having one does not eliminate the benefit or need for the other.

B. "My health care proxy designee is not able to sign a consent form on my behalf.": The designee named in a health care proxy is specifically authorized to make healthcare decisions, including signing consent forms, if the client becomes unable to do so themselves.

C. "I do not need to name a relative as my designee in my health care proxy.": A client can choose any competent adult they trust to act as their healthcare proxy; it does not have to be a relative. This flexibility allows clients to select someone they believe will best honor their wishes.

D. "Once my health care proxy is in place, I relinquish my right to make my own decisions.": Having a health care proxy does not remove the client's decision-making rights. The proxy only takes effect if the client becomes unable to make or communicate their own healthcare decisions.

A. Report the blood pressure reading to the charge nurse: While notifying the charge nurse is important, the nurse should first validate the high reading by rechecking the blood pressure. Acting on a single, unverified reading could lead to unnecessary interventions or missed opportunities for accurate assessment.

B. Administer an antihypertensive medication: Administering antihypertensive medication based solely on a report without rechecking the blood pressure could be unsafe. Verification ensures that treatment is based on accurate clinical data and prevents unnecessary medication administration.

C. Remeasure the client's blood pressure: The first action should always be to recheck an unusually high or abnormal vital sign reading to confirm its accuracy. Errors can occur during measurement, and accurate confirmation is critical before proceeding with further interventions in a client with chronic kidney failure.

D. Instruct the client to remain in bed: While keeping the client in bed can help prevent complications if severe hypertension is confirmed, it is not the priority action. Verifying the blood pressure reading must occur first to determine the appropriate course of action.