A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?

Choice A Reason:

“I understand that you decided not to receive blood products.” This response shows empathy and acknowledges the client's decision without judgment. It respects the client's autonomy and decision-making capacity.

Choice B Reason:

“Not receiving blood will slow down your memory.” This statement introduces a potential consequence that may not be accurate or relevant to the client's decision. It is important to provide information, but scare tactics or inaccurate statements may not be helpful.

Choice C Reason:

“Why are you refusing to receive blood products?” While understanding the client's rationale is essential, the initial response should convey empathy and acceptance. Asking why may be appropriate later in the conversation, but starting with understanding is crucial.

Choice D Reason:

“You need to talk with your doctor about this.” While involving the doctor is important, it's essential to address the client's feelings and decisions directly. The nurse can play a supportive role in facilitating communication between the client and the healthcare team.

A. Check a client's peripheral IV site for redness or swelling.
This task involves assessing the client's IV site for signs of complications. While it requires observation and reporting, it may involve some interpretation and judgment. This task is better suited for a licensed nurse.

B. Measure the intake and output of a client who has received furosemide.
Measuring intake and output is a routine task that involves quantifying the fluids a client consumes and eliminates. This is a task that can be appropriately delegated to an assistive personnel (AP) under the supervision and direction of the nurse.

C. Reinforce teaching with a client about crutch-gait walking.
Teaching requires a level of education, explanation, and clarification that goes beyond routine tasks. This is typically a nursing responsibility and should not be delegated to an AP.

D. Assess the pain level of a client who has received acetaminophen.
Pain assessment involves subjective information, and determining the appropriate response may require clinical judgment. This task is better suited for a licensed nurse.