A public health nurse will be administering immunizations at a clinic. Which of the following will the nurse want to ask each client before administering the vaccine to ensure safety?

Choice A Reason:
Assessing the client's wound is a task that requires clinical judgment and expertise, which falls under the scope of practice of a registered nurse (RN) or licensed practical nurse (LPN). Assistive personnel (AP) are not trained or authorized to perform assessments, as these require a higher level of clinical knowledge and decision-making.

Choice B Reason:
Notifying the case manager of the client's wishes for community resources involves communication and coordination of care, which are responsibilities typically handled by an RN or LPN. This task requires understanding the client's overall care plan and the ability to communicate effectively with other healthcare professionals.

Choice C Reason:
Reviewing the client's medications is a task that involves understanding the medications, their purposes, potential side effects, and interactions. This requires clinical knowledge and judgment, which are beyond the scope of practice for AP. Medication review is typically performed by an RN or LPN.

Choice D Reason:
Assisting the client with bathing and oral care is a task that falls within the scope of practice for AP. These activities are part of the basic care tasks that AP are trained to perform. They involve helping the client with daily living activities, which do not require clinical judgment or decision-making.

Choice A Reason:
Ensuring the client has been taking their prescribed diuretic is important in managing heart failure. Diuretics help reduce fluid buildup, which can alleviate symptoms like edema and weight gain. However, this action alone may not be sufficient if the patient is already experiencing significant symptoms. Immediate consultation with a healthcare provider is necessary to adjust the treatment plan appropriately.

Choice B Reason:
Reinforcing the importance of daily weights is a crucial educational intervention for patients with heart failure. Monitoring daily weight helps in early detection of fluid retention, allowing for timely intervention. However, given the patient's current symptoms of significant weight gain and generalized edema, immediate action is required beyond just reinforcing education.

Choice C Reason:
Documenting the findings and continuing with the visit is part of the nurse's responsibilities. Accurate documentation is essential for tracking the patient's condition over time. However, in this scenario, the patient's symptoms indicate a potential exacerbation of heart failure, which requires prompt medical attention. Simply documenting without taking further action is not sufficient.

Choice D Reason:
Calling the healthcare provider for further instructions is the most appropriate action in this situation. The patient's weight gain and generalized edema suggest worsening heart failure, which may require adjustments in medication or other interventions. Immediate consultation with the healthcare provider ensures that the patient receives timely and appropriate care to prevent further complications.