A nurse is supervising an assistive personnel (AP) who is providing client care. The nurse should identify that which of the following actions by the AP demonstrates effective use of supplies?

• Temperature 35.3°C (95.5°F): Hypothermia following surgery is concerning because it may reflect poor perfusion, internal bleeding, or shock. Immediate warming measures and evaluation are necessary to prevent further deterioration.
• Blood pressure 90/60 mm Hg: The client’s blood pressure is lower than previous values and indicates potential hypovolemia or ongoing blood loss. Hypotension post-surgery must be urgently addressed to avoid progression to shock.
• Skin cool and moist to touch: Cool, moist skin is an early clinical sign of decreased tissue perfusion and shock. When found alongside hypotension and hypothermia, it suggests that circulatory compromise may already be developing.
• Moderate amount of sanguineous drainage noted on lower dressing: Moderate bleeding post-laparoscopic surgery is abnormal. This finding, in combination with hypotension and other signs of poor perfusion, strongly suggests possible internal bleeding requiring urgent provider notification.
• Hypoactive bowel sounds: Hypoactive bowel sounds are expected after abdominal surgery due to anesthesia and reduced gut motility. They are not an immediate sign of a critical complication unless accompanied by abdominal distension or severe pain, they should however be monitored.
• Heart rate 60/min: A heart rate of 60/min is at the lower limit of normal. Although 60/min is still technically within normal range, the trend of decreasing heart rate from baseline 90 beats/min, especially in the setting of hypotension and signs of poor perfusion, is concerning. This decline may indicate worsening hemodynamic status and must be monitored closely for further deterioration..
• Pedal pulse +1 bilateral: Diminished pedal pulses (+1) indicate reduced peripheral circulation. In isolation, it may not be critical, but when combined with hypotension and cool skin, it becomes part of the overall picture suggesting decreased perfusion and should be monitored carefully.

A. "I will support your decision and help you explain it to others.": This response respects the client's autonomy and decision-making rights. It also offers emotional support and assistance in communicating the client's wishes to other healthcare team members or family, promoting dignity and advocacy.

B. "Let me explain the pros and cons of your decision.": This response may sound judgmental and suggest that the nurse is trying to influence the client's decision. Once a competent client has made a choice, the nurse’s role is to support it rather than attempt to persuade or second-guess it.

C. "I suggest you discuss this decision with your family first.": While family discussions can be valuable, the client has the primary right to make healthcare decisions. Suggesting they must discuss it with family could delay honoring the client’s wishes or create unnecessary emotional pressure.

D. "I will send the social worker in to discuss this decision with you.": While a social worker can provide additional support, immediately deferring to someone else instead of acknowledging the client’s decision can make the client feel dismissed. The nurse should first validate and support the client’s expressed wishes.