A nurse is monitoring a client’s oxygen saturation using a pulse oximeter. The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula.
Which of the following actions should the nurse take?

This is because a frayed electrical cord can pose a serious risk of electric shock or fire to the client and the nurse.

The nurse should act quickly to eliminate the hazard and ensure the safety of the client and others.

Choice B is wrong because accessing the facility’s maintenance protocol is not the first action the nurse should take.

The nurse should prioritize removing the device from the room before following any protocol.

Choice C is wrong because reporting defective equipment is not the first action the nurse should take.

The nurse should prioritize removing the device from the room before reporting it to the appropriate authority.

Choice D is wrong because requesting a replacement device is not the first action the nurse should take.

The nurse should prioritize removing the device from the room before requesting a new one.

- When coordinating the care of a group of clients with assistive personnel (AP), it's important to delegate tasks appropriately based on the AP's scope of practice and training. Here are the tasks that can be assigned to the AP:

Measure the intake and output of a client who has received furosemide: This task involves recording fluid intake and output, which is typically within the scope of practice for an AP, as long as they have been trained in the proper procedure and documentation.

Check a client’s peripheral IV site for redness or swelling: This task involves basic assessment and can be assigned to an AP, as long as they are familiar with the signs of potential complications related to IV sites and have been trained in the facility's protocol for reporting any issues.

Reinforcing teaching with a client about crutch-gait walking: Education and reinforcement of information provided by healthcare professionals can often be delegated to APs, especially if they have received training on the specific topic. However, it's important to ensure that the AP is knowledgeable about crutch-gait walking and the information they are reinforcing.

The task related to assessing pain (e.g., assessing the pain level of a client who has received acetaminophen) should generally be performed by a licensed healthcare provider, such as a nurse. Assessment of pain requires a deeper understanding of the client's pain experience and may involve making clinical decisions related to pain management.