A nurse is reporting a client’s laboratory tests to the provider to obtain a prescription for the client’s daily warfarin.
Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?

B. Review the skill level and qualifications of each AP.

Before delegating tasks, the nurse should assess the skill level and qualifications of each AP to ensure they have the necessary knowledge and training to perform the assigned tasks safely and effectively.

D. Communicate appropriate tasks to the APs with specific expectations.

The nurse should clearly communicate the tasks to be delegated to each AP. This includes providing specific instructions, expectations, and any necessary information to ensure the APs understand what is expected of them and can perform the tasks correctly.

A. Monitor progress of task completion with each AP.

Once the tasks are assigned, the nurse should periodically check in with each AP to monitor the progress of task completion. This allows the nurse to provide support, answer questions, and ensure that tasks are being performed as expected.

C. Evaluate the APs' performance of each task.

After the tasks are completed, the nurse should evaluate the APs' performance of each task. This evaluation helps identify any areas for improvement, additional training needs, and overall competency of the APs.

Delegating tasks to assistive personnel is an essential aspect of nursing practice. Following this sequence of steps helps ensure that tasks are delegated appropriately and that the care provided is safe, efficient, and aligned with the APs' capabilities. Regular communication and feedback are essential to effective task delegation and teamwork within the healthcare setting.

The correct answer is Choice B

Choice A rationale: Inserting the catheter without applying suction is correct technique. Suction should only be applied while withdrawing the catheter to prevent mucosal trauma and hypoxia. Initiating suction during insertion can damage tracheal lining and cause bradycardia due to vagal stimulation. Allowing clean insertion without suction reduces injury risk and supports effective secretion removal on withdrawal with controlled suction time.

Choice B rationale: Waiting 2 minutes between suction passes is too long and may delay secretion clearance, risking hypoxia and secretion buildup. Best practice is to wait about 30 seconds to 1 minute or until the client recovers baseline oxygen saturation and heart rate. Prolonged intervals may lead to atelectasis or respiratory distress in patients with poor reserve, especially if suctioning is incomplete or secretions are copious.

Choice C rationale: Suctioning should be limited to 10–15 seconds per pass to reduce hypoxemia and bronchospasm risks. Applying suction for 15 seconds falls within the upper acceptable range, particularly if preoxygenation is done. Extended suction beyond this can decrease PaO₂ levels rapidly. Limiting the suction time ensures safer removal of secretions while minimizing trauma and preserving adequate oxygenation.

Choice D rationale: Encouraging the client to cough facilitates mobilization of secretions toward the upper airway, making suctioning more effective. Coughing also enhances airway clearance naturally and may reduce the number of required suction passes. It is a therapeutic action in tracheostomy care that supports pulmonary hygiene, helps prevent atelectasis, and can reduce the need for deep suctioning interventions.