A nurse is preparing to administer an IM injection for an infant. Which of the following actions should the nurse take?

Rationale for correct choices

• an endoscopy: The client reports a 3-week history of gnawing, burning epigastric pain that radiates to the back, worsens after meals, and is accompanied by one episode of dark, tarry stool. These symptoms suggest a possible peptic ulcer or gastrointestinal bleeding. An endoscopy is the definitive diagnostic procedure to visualize the gastric mucosa, identify ulcers, and assess for bleeding.

• stool test results: The presence of a dark, tarry stool indicates possible gastrointestinal bleeding (melena). Stool testing, such as a fecal occult blood test, provides objective evidence of bleeding and guides the urgency and necessity of endoscopy. This finding is a key indicator for further gastrointestinal evaluation.

Rationale for incorrect choices

• oxygen via nonrebreather mask: The client’s respiratory assessment shows bilateral clear breath sounds and no signs of hypoxia. Oxygen therapy is not indicated based on current findings, as there is no respiratory compromise.

• an antifungal prescription: There is no evidence of fungal infection. The client’s symptoms are consistent with gastrointestinal pathology, not a fungal etiology. Prescribing an antifungal would be inappropriate without clinical or laboratory indications.

• respiratory rate: The respiratory rate is normal and does not correlate with the presenting gastrointestinal symptoms. It is not a primary indicator for diagnostic intervention in this case.

• temperature: The client does not report fever or signs of infection at this time. While monitoring temperature is standard, it is not a primary indicator for diagnosing peptic ulcer disease or gastrointestinal bleeding in this scenario.

Rationale:

A. Assign the AP to ask the client if she has taken her antidiabetic medication today: Asking about medication adherence is part of assessment and requires clinical judgment. Delegating this task to an AP is inappropriate because it involves interpreting client responses and making clinical decisions.

B. Determine if the AP has the skills to perform the test: Before delegating any task, the nurse must verify that the AP is competent and trained to perform the procedure safely. Ensuring skill competency protects the client from harm and aligns with the nurse’s responsibility for delegation.

C. Have the AP check the medical record for prior blood glucose test results: Reviewing medical records and interpreting trends involves clinical judgment and falls outside the typical scope of practice for an AP. This task should remain with the licensed nurse.

D. Help the AP perform the blood glucose test: Assisting the AP is not necessary if the AP is competent and has been properly trained. The nurse’s role is to delegate appropriately, supervise as needed, and ensure safe completion, rather than performing the task alongside the AP.