A nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first?

Client 3: Collect and label specimen.

Assistive personnel- Assistive personnel can handle the collection and labeling of specimens, which is a routine task that does not require advanced clinical judgment.

Client 1: Perform prescribed procedure.

Practical Nurse- Insertion of a nasogastric tube is a procedure that requires clinical skills and knowledge, making it appropriate for a licensed practical nurse (LPN) to perform.

Client 3: Administer prescribed medication.

Practical Nurse- Administering medication is within the scope of practice for a practical nurse, as they are trained to handle medications and monitor their effects.

Client 4: Perform prescribed testing.

Assistive personnel- Testing such as using a glucometer for blood glucose monitoring can be performed by assistive personnel under the supervision of a registered nurse or practical nurse.

Client 4: Provide prescribed wound care.

Practical Nurse- Wound care, especially for a non-healing wound and cellulitis, requires clinical assessment and skills that a practical nurse is trained to provide.

Client 2: Transport client for diagnostic testing.

Assistive personnel- Transporting clients to diagnostic testing is a task that can be safely performed by assistive personnel.

A. "The client works in the hospital radiology department": This information is irrelevant to the client’s current health status and does not imply a need for total care by the nurse.

B. "The client discussed having prior thoughts of suicide": While suicidal ideation is serious and requires careful monitoring and assessment, this information alone does not necessarily indicate that the nurse must assume total care. A nurse would still delegate non-critical tasks to the AP, but constant monitoring and appropriate interventions would still be the nurse’s responsibility.

C. "The client's blood pressure and pulse have been fluctuating throughout the day": Fluctuating vital signs, especially blood pressure and pulse, can indicate an unstable condition that may require immediate attention and careful monitoring. This scenario suggests that the client’s condition may be critical and requires ongoing assessment and evaluation by the nurse, rather than simply delegating tasks like monitoring vital signs to assistive personnel (AP). The nurse needs to assess the situation thoroughly, interpret the fluctuations, and adjust the care plan accordingly.

D. "The client's family members have been present most of the day": Family presence alone does not impact the need for total care by the nurse. It is important for the nurse to communicate with the family, but this statement does not indicate the need for the nurse to assume total care over other team members.