A nurse is delegating tasks to a group of staff members. Which of the following tasks should the nurse assign to an assistive personnel?

Rationale:

A. Discuss the client's preferences for determining a repositioning schedule: While involving the client in care planning is important, the schedule for repositioning is primarily determined by clinical needs to prevent complications such as pressure injuries, not solely by preference.

B. Evaluate the client's ability to help with repositioning: Assessing the client’s strength, mobility, and coordination after a stroke determines the level of assistance and equipment required. This ensures safety for both the client and the nurse during repositioning.

C. Raise the side rails of the client’s bed during repositioning: Side rails can create entrapment hazards if used incorrectly and should not be relied upon during repositioning. Their purpose is more for safety positioning after the move, not as a primary tool during the maneuver.

D. Reposition the client with the assistive devices: Assistive devices should be used if needed, but this step follows an assessment of the client’s capabilities. Selecting equipment without first evaluating the client may lead to unnecessary interventions.

Rationale for correct choices:

• Skin feels cool to the touch: Cool skin indicates poor peripheral perfusion, which can signal early hypovolemic shock in a child with burns. Prompt assessment and interventions, such as fluid resuscitation, are necessary.
• Capillary refill 3 seconds in left foot: Delayed capillary refill reflects compromised circulation and decreased tissue perfusion. Early recognition and intervention help prevent progression to shock.
• Blood pressure 102/50 mm Hg: Mild hypotension combined with tachycardia, cool skin, and delayed capillary refill suggests early hypovolemic shock, a life-threatening complication requiring immediate attention.
• Temperature 35.8° C (96.4° F): Hypothermia can occur due to heat loss from burn injuries, increasing the risk for coagulopathy, impaired wound healing, and further hemodynamic instability.
• Output of 25 mL dark amber urine through catheter: Low and concentrated urine output indicates possible dehydration or reduced renal perfusion, which can progress to acute kidney injury if not addressed urgently.

Rationale for incorrect choices:

• Respiratory rate 20/min: Although slightly decreased from admission, this is within a near-normal range for an 8-year-old and not immediately concerning. Continuous monitoring is appropriate, but it is not an urgent priority compared with perfusion and hemodynamic indicators.
• Dressing on left hand shows small amount of moisture through gauze: Minor moisture in the dressing may reflect mild wound exudate, which requires routine monitoring and dressing changes. It does not indicate an immediate life-threatening risk.