A nurse is collecting data from a client who is malnourished due to inflammatory bowel disease. Which of the following findings should the nurse expect?

A. Measure the intake and output of a client who has received furosemide: Measuring intake and output is within the scope of practice for assistive personnel. The nurse remains responsible for interpreting the data and notifying the provider of any concerns.

B. Check a client's peripheral IV site for redness or swelling: Assessment of IV sites for complications such as infiltration, phlebitis, or infection requires clinical judgment and should be performed by licensed nursing personnel.

C. Assess the pain level of a client who has received acetaminophen: Pain assessment requires clinical judgment, interpretation of client responses, and knowledge of pain scales. Only licensed nurses should perform pain assessments and determine the effectiveness of interventions.

D. Reinforce teaching with a client about crutch-gait walking: Reinforcing teaching involves understanding and communicating clinical concepts accurately. Even though it may seem routine, instructing or clarifying a gait technique requires nursing knowledge to ensure client safety and proper technique.

A. "He is allergic to sulfa." Communicating a client’s allergies during transfer is critical to ensure patient safety and prevent adverse reactions. This information directly impacts medication administration and care planning on the receiving unit, making it essential to include in the transfer report.

B. "His partner has been visiting." While family involvement can be helpful, details about visitors are generally less urgent and not typically necessary in a transfer report unless they directly affect the client’s care or safety.

C. "He appears anxious about the transfer." Emotional status is important but is secondary to clinical information. If anxiety significantly affects the client’s care or safety, it might be mentioned, but it is not a priority in a transfer report focused on immediate clinical needs.

D. "He is voiding adequately." Although voiding status is relevant to some clients’ care, it is less critical than allergy information unless the client has a specific condition affecting urinary function that requires close monitoring. The allergy detail remains a higher priority in transfer communication.