The charge nurse observes a new nurse during the administration of two different liquid medications at once through a gastrostomy tube used for enteral feeding. The charge nurse observes the new nurse's actions. What action(s) should the charge nurse take? (Select all that apply.)

Choice A: Obtain a blood pressure reading before the client gets out of bed. This is the most important intervention, as it can prevent or detect orthostatic hypotension, which is a drop in blood pressure when changing position from lying to standing. Orthostatic hypotension can cause dizziness, fainting, or falls, and it can be caused by medications, dehydration, or cardiac problems.

Choice B: Monitor and record the client's urinary output every day. This is not the most important intervention, as it does not address the client's anxiety or adjustment issues. The urinary output should be monitored for signs of fluid balance, kidney function, or infection, but it is not a priority for this client.

Choice C: Provide the client with teaching regarding a cardiac diet. This is not the most important intervention, as it does not address the client's anxiety or adjustment issues. The cardiac diet should be taught to promote heart health, lower cholesterol, and reduce sodium intake, but it is not a priority for this client.

Choice D: Assess the client's vital signs every 4 hours when awake. This is not the most important intervention, as it does not address the client's anxiety or adjustment issues. The vital signs should be assessed for signs of infection, pain, or hemodynamic instability, but they are not a priority for this client.

The correct answer is A:

Choice A reason: Review the need for the UAP to wear a face mask while in close contact with the client. Influenza is a respiratory virus that spreads mainly by droplets made when people with flu cough, sneeze or talk.A face mask can help block the spread of these droplets.

Choice B reason:Reminding the UAP to apply a fitted respirator mask before entering the client’s room is not necessary for standard influenza precautions.Respirator masks are more commonly used for airborne precautions, such as tuberculosis or measles, not for influenza.

Choice C reason:Assigning the UAP to provide care for another client and assuming full care of the client is not indicated unless the UAP is not following proper infection control procedures.There is no evidence of that in the scenario provided.

Choice D reason:Instructing the UAP to notify the nurse of any changes in the client’s respiratory status is important, but it is not the immediate action related to infection control.The priority is to prevent the spread of infection.