The nurse is continuing to care for the adolescent.

Admission Assessment

1400:

Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.

Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Which of the following prescriptions should the nurse anticipate from the provider?

Choice A reason:

Urine specific gravity should not be reported by the nurse. While urine specific gravity is an important indicator of hydration status and kidney function, the provided information does not suggest any abnormalities in urinary output or signs of kidney issues. It is not the most critical finding to report in this scenario.

Choice B reason:

Prealbumin should not be reported by the nurse. Prealbumin is a protein used to assess nutritional status, but its significance in this situation is not apparent from the provided data. It may be relevant in other contexts, such as assessing malnutrition, but it does not directly address the current findings.

Choice C reason:

Temperature should not be reported by the nurse. The provided information does not include any data about the client's temperature, and there are no signs of infection mentioned. While temperature is an important vital sign, it is not relevant to the findings presented in this scenario.

Choice D reason

The nurse should report the "hypoactive bowel sounds upon auscultation" to the provider. Hypoactive bowel sounds can be a sign of gastrointestinal (GI) motility issues, which may indicate a potential problem with the client's digestive system. It could be due to various causes such as bowel obstruction, inflammation, or other GI disorders. Reporting this finding to the provider is essential so that appropriate assessments and interventions can be taken to address the client's condition.

A. Incorrect. Performing gastrostomy feedings is a complex task that requires specialized training and assessment skills. The nurse should not delegate this task to an AP who has not received the appropriate education and competency validation.

B. Correct. Determining if the PRN pain medication has helped is a simple task that involves asking the client about their pain level and documenting the response. The nurse can delegate this task to an AP as long as they follow up with the client and evaluate the effectiveness of the pain management plan.

C. Incorrect. Providing instructions about client care to a family member over the telephone is a task that requires clinical judgment and communication skills. The nurse should not delegate this task to an AP who might not have the knowledge or authority to answer questions or address concerns.

D. Incorrect. Teaching a client how to measure their own blood pressure is a task that requires teaching and evaluation skills. The nurse should not delegate this task to an AP who might not be able to explain the procedure, demonstrate the technique, or assess the client's learning.