A nurse is providing a handoff report using the introduction, situation, background, assessment, recommendation, and readback (ISBARR) on a client. Which of the following information should be included in the situation component?

Choice A reason: Irrigating and performing a dressing change for a client who has a pressure injury wound is not a task that the nurse should delegate to an AP. This task requires the nurse's clinical judgment, skill, and knowledge to assess the wound, select the appropriate dressing, and prevent infection. This task is also within the nurse's scope of practice, but not the AP's scope of practice.

Choice B reason: Administering oral PRN pain medication to a client who has arthritis is not a task that the nurse should delegate to an AP. This task involves the nurse's responsibility to evaluate the client's pain level, determine the need and the dosage of the medication, and monitor the client's response and side effects. This task is also within the nurse's scope of practice, but not the AP's scope of practice.

Choice C reason: Obtaining a daily weight on a client who has heart failure is a task that the nurse can delegate to an AP. This task is a routine and standardized procedure that does not require the nurse's clinical judgment, skill, or knowledge. This task is also within the AP's scope of practice, if the nurse provides clear directions and supervision.

Choice D reason: Reinforcing teaching the use of an incentive spirometer to a postoperative client is not a task that the nurse should delegate to an AP. This task involves the nurse's role to educate the client about the purpose, benefits, and technique of using the incentive spirometer, and to evaluate the client's understanding and compliance. This task is also within the nurse's scope of practice, but not the AP's scope of practice.

Choice A reason: This statement is incorrect because right documentation is not one of the five rights of delegation. Right documentation is a responsibility of the nurse and the AP, but it is not a criterion for deciding what tasks to delegate and to whom. The five rights of delegation are right task, right circumstance, right person, right direction, and right supervision.
Choice B reason: This statement is correct because right communication is one of the five rights of delegation. Right communication means that the nurse provides clear, concise, and specific instructions to the AP, and that the AP acknowledges and understands the instructions. Right communication also involves feedback, reporting, and documentation between the nurse and the AP.
Choice C reason: This statement is incorrect because right time is not one of the five rights of delegation. Right time is a factor that affects the delegation process, but it is not a criterion for deciding what tasks to delegate and to whom. The five rights of delegation are right task, right circumstance, right person, right direction, and right supervision.
Choice D reason: This statement is incorrect because right room is not one of the five rights of delegation. Right room is a factor that affects the delegation process, but it is not a criterion for deciding what tasks to delegate and to whom. The five rights of delegation are right task, right circumstance, right person, right direction, and right supervision.