A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make?

Rationale:

A. The nurse should dispose of the ampule in the trash can: Glass ampules are considered sharps and must be disposed of in a designated sharps container to prevent injury and maintain safety. Throwing them in regular trash is unsafe and violates standard precautions.

B. The nurse should use the same needle to draw up and inject the client: Using the same needle can introduce glass particles or contamination into the client’s tissue. A new sterile needle should be used for injection after withdrawing the medication to ensure safety and sterility.

C. The nurse should use a filter needle to withdraw the medication: A filter needle is designed to prevent small glass shards from being drawn into the syringe when breaking the ampule. This action protects the client from injury and ensures that the medication administered is free from particulate matter.

D. The nurse should break the neck of the ampule toward their body: The ampule should always be broken away from the body to prevent injury from glass shards. Breaking it toward oneself increases the risk of cuts and contamination, making it an unsafe practice.

Rationale:

A. Assign the AP to ask the client if she has taken her antidiabetic medication today: Asking about medication adherence is part of assessment and requires clinical judgment. Delegating this task to an AP is inappropriate because it involves interpreting client responses and making clinical decisions.

B. Determine if the AP has the skills to perform the test: Before delegating any task, the nurse must verify that the AP is competent and trained to perform the procedure safely. Ensuring skill competency protects the client from harm and aligns with the nurse’s responsibility for delegation.

C. Have the AP check the medical record for prior blood glucose test results: Reviewing medical records and interpreting trends involves clinical judgment and falls outside the typical scope of practice for an AP. This task should remain with the licensed nurse.

D. Help the AP perform the blood glucose test: Assisting the AP is not necessary if the AP is competent and has been properly trained. The nurse’s role is to delegate appropriately, supervise as needed, and ensure safe completion, rather than performing the task alongside the AP.