A nurse is caring for a client who has a spinal cord injury. Which of the following support devices should the nurse plan to use to prevent plantar flexion contractures?

Rationale:

A. SpO₂: Although 88% is low for the general population, it is often an acceptable baseline for clients with COPD. Their oxygen saturation targets are typically between 88–92% to avoid suppressing respiratory drive, so this value may not require immediate provider notification.

B. pH: A pH of 7.22 indicates respiratory acidosis, which is a serious and potentially life-threatening complication of COPD. This level of acidosis shows that the client’s ventilation is inadequate, and immediate intervention is needed. This is the most critical finding that requires provider notification.

C. Respiratory rate: A rate of 22 breaths/min is slightly elevated but not critical. It may be compensatory and expected in a COPD patient who is hypoxic or retaining CO₂. By itself, it doesn't warrant urgent notification unless it worsens.

D. Temperature: A temperature of 37.2°C (99°F) is within the normal range and does not indicate infection or acute illness. It is not a finding that necessitates notifying the provider at this point.

Rationale:

A. You should not delegate this task because it requires nursing judgment: Weighing clients is a routine, non-invasive task that does not involve clinical decision-making. It does not require nursing judgment and is appropriate for delegation if the AP is competent.

B. You can delegate this task to an AP for new clients before performing a nursing assessment: Initial assessments must be performed by a licensed nurse. Weighing can be part of the assessment, but the nurse should first evaluate the client to determine whether delegation is appropriate.

C. You can delegate this task if the AP has been trained to use our scales: Delegation depends on the AP’s competence and familiarity with facility equipment. If trained, the AP can safely and accurately weigh clients, freeing the nurse for tasks requiring professional judgment.

D. You should not delegate this task because you have the capability to obtain clients weights: Delegation decisions should be based on scope of practice and task appropriateness, not whether the nurse is physically able to perform the task. Efficient delegation supports safe and effective care delivery.