A nurse is planning care for a client who has a chest tube. Which of the following interventions should the nurse include in the plan? (Select all that apply)

Rationale:

A. Obtaining the initial assessment of assigned clients: Initial assessments require nursing judgment and are part of the nursing process, which cannot be delegated to assistive personnel. Only licensed nurses may perform comprehensive initial assessments.

B. Changing a nonsterile dressing: This is a routine and predictable task that does not require clinical judgment and can be safely delegated to assistive personnel, depending on facility policy and the client’s condition.

C. Interpreting a client's diagnostic laboratory results: Interpretation of lab values requires analysis and clinical decision-making, which are nursing responsibilities. Assistive personnel are not licensed to interpret or evaluate clinical data.

D. Educating a client and family members on home care: Client education involves assessing understanding, using clinical knowledge, and adapting teaching methods, functions reserved for licensed nurses, not assistive personnel.

Rationale:

• Temperature: The child’s temperature is 37.4°C (99.3°F), which is mildly elevated. Crohn’s disease typically causes intermittent fever during flare-ups. Appendicitis often presents with a higher fever in later stages. Intussusception can cause low-grade fever due to bowel inflammation, making it the most consistent with this finding.
• Vomiting: Vomiting is uncommon in Crohn’s disease unless there’s obstruction or severe disease. In appendicitis, vomiting usually follows the onset of pain and is related to peritoneal irritation. Intussusception often involves vomiting early due to intermittent bowel obstruction, making it consistent with this client’s symptoms.
• Pain rating: A FLACC score of 5 indicates moderate pain. Crohn’s pain tends to be chronic and crampy rather than episodic. Appendicitis pain worsens over time and becomes localized, typically in the right lower quadrant. Intussusception causes intermittent, severe abdominal pain with sudden relief, matching the child’s pain episodes and behavior.
• Abdominal findings: Crohn’s disease rarely produces a palpable abdominal mass or sudden distension. Appendicitis can cause right-sided tenderness and decreased bowel sounds but does not typically involve a mass. Intussusception often presents with a distended abdomen, hypoactive bowel sounds, and a sausage-shaped mass in the right upper quadrant, as described.
• Stool: Crohn’s disease can lead to bloody, mucus-filled stools due to ulceration in the intestinal lining. Appendicitis does not typically alter stool characteristics unless perforation occurs. Intussusception is well known for producing “currant jelly” stools, composed of blood and mucus, aligning with this child’s bowel movement description.