A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?

Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge.

Membranes intact.

No uterine contractions noted.

FHR baseline 138, with minimal variability. No further reports of burning with urination.

Laboratory Results: WBC 12,000/mm3 (within the normal range of 5,000 to 10,000/mm3). Platelet count 188,000/mm3 (within the normal range of 150,000 to 400,000/mm3).

Vital Signs: Temperature 37.1°C (98.7°F), Blood pressure 120/78 mm Hg.

Choice A rationale:

Transferring a client to physical therapy is a task that can be safely delegated to an assistive personnel (AP) as long as the client does not have any specific medical restrictions or requires specialized assistance during the transfer. APs are trained to assist with activities of daily living, including transferring clients from one place to another. However, it is essential for the nurse to assess the client's condition and provide clear instructions to the AP to ensure a safe transfer.

Choice B rationale:

Obtaining a client's vital signs every 4 hours is a routine task that can be delegated to an assistive personnel. APs are trained to measure vital signs such as blood pressure, heart rate, respiratory rate, and temperature under the supervision of licensed healthcare providers. Regular monitoring of vital signs is crucial in assessing the client's overall health status and detecting any changes that might require immediate medical attention.

Choice E rationale:

Recording a client's intake after each meal is a task that can be delegated to an assistive personnel. APs can document the amount and type of food and fluids consumed by the client. Monitoring the client's intake is important, especially if the client has specific dietary restrictions, allergies, or medical conditions that require close monitoring of their food and fluid intake.

Choice C rationale:

Instructing a client on the use of an incentive spirometer requires specialized knowledge and assessment of the client's respiratory status. This task should be performed by a licensed healthcare provider, such as a nurse or respiratory therapist, who can properly assess the client's lung function, demonstrate the correct technique, and ensure the client's safety during the process. Delegating this task to an AP could result in improper use of the spirometer, potentially leading to complications or ineffective therapy.

Choice D rationale:

Inserting an NG tube for a client who requires enteral feedings is a complex medical procedure that should be performed by a licensed nurse or healthcare provider with appropriate training and expertise. This procedure carries risks, including the risk of aspiration if not done correctly. Delegating this task to an AP is outside their scope of practice and could jeopardize the client's safety.