A nurse is reviewing risk factors for a client who had a myocardial infarction. Which of the following should the nurse consider to be a nonmodifiable risk factor?

A. An assistive personnel can evaluate a client's response to medication: Assistive personnel do not have the education or licensure to evaluate medication effects. They can perform delegated tasks such as vital signs or basic care, but assessment and evaluation of clinical responses remain within the RN’s scope of practice.

B. An RN can initiate the plan of care for a client on admission: Registered nurses are responsible for performing assessments, identifying nursing diagnoses, and developing an individualized plan of care upon admission. This is a core component of the RN’s legal scope of practice and requires professional judgment.

C. An RN can delegate blood administration to a licensed practical nurse: Blood administration is a high-risk procedure that generally cannot be delegated to an LPN in many states due to its complexity and potential for adverse reactions. The RN retains responsibility for administration and monitoring.

D. A licensed practical nurse can provide initial discharge instructions: Providing initial discharge instructions requires comprehensive assessment, education, and evaluation, which are within the RN’s scope of practice. LPNs may reinforce education but cannot independently provide initial instructions.

A. Discuss the incident with the health care worker: While addressing the suspected impairment with the worker is important, immediate removal from the work environment takes priority to ensure patient safety and prevent potential harm. Confrontation can follow after securing a safe environment.

B. Document the findings of the incident: Documentation is essential for legal and professional accountability, but it is secondary to protecting patients from immediate risk. Recording observations does not prevent ongoing exposure to unsafe practice.

C. Remove the health care worker from the work environment: The first priority is ensuring patient safety. Suspected chemical impairment can impair judgment, coordination, and response time, creating a high risk for errors or accidents. Immediate removal prevents potential harm to clients and coworkers.

D. Place the health care worker on probation: Probation is a disciplinary measure that may follow an investigation, but it is not the first step. Immediate action must focus on safety, and probation does not address the urgent risk posed by active impairment.