A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make?

A: Correct. Applying thromboembolic stockings (compression stockings) to the client's legs is a task that can be safely delegated to assistive personnel. The nurse should provide clear instructions on how to apply them properly.
B: Incorrect. Monitoring the circulation in all four extremities requires clinical judgment and skilled assessment, and it should not be delegated to assistive personnel.
C: Incorrect. Recording the condition of the client's skin requires observation and assessment, which should not be delegated to assistive personnel.

The correct answer is Choice B.

Choice A rationale: Placing the client in a room with another client who has pharyngitis is not recommended. Pharyngitis can be caused by various different pathogens, not just streptococci. Co-housing clients with different infections can lead to cross-infection, complicating both clients’ conditions. Therefore, this choice is not the best option.

Choice B rationale: Ensuring that the client wears a surgical mask during transportation throughout the facility is the correct choice. Streptococcal infections are spread through respiratory droplets. A surgical mask can help prevent the spread of these droplets, protecting other clients and healthcare workers in the facility. This is a standard precaution in infection control.

Choice C rationale: Limiting the client’s visitors to visitations of 30 minutes is not necessarily beneficial. The duration of the visit does not significantly impact the risk of transmission as much as the precautions taken during the visit, such as hand hygiene and wearing a mask. Therefore, while limiting visitation time might reduce exposure, it is not the most effective measure to prevent the spread of infection.

Choice D rationale: Providing the client a room with negative pressure airflow of six air exchanges per hour is not necessary for a client with a streptococcal infection. Negative pressure rooms are typically used for clients with airborne diseases, such as tuberculosis. A streptococcal infection is spread through droplets, not airborne transmission, so a negative pressure room would not provide any additional benefit.