The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the PN?

Choice A Reason: Identifying locations of skin lesions on a newly admitted client is a nursing assessment that requires clinical judgment and cannot be delegated to the UAP.

Choice B Reason: Emptying the ostomy bag for a client with a temporary colostomy is a routine task that does not require clinical judgment and can be delegated to the UAP.

Choice C Reason: Providing a complete bed bath for a comatose client is a routine task that does not require clinical judgment and can be delegated to the UAP.

Choice D Reason: Performing foot care including toenail trimming and heel care is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP. The UAP may cause injury or infection to the client's feet, especially if the client has diabetes or peripheral vascular disease.

Choice E Reason: Giving mouth care to an elderly client who has a tracheostomy is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP. The UAP may cause trauma or aspiration to the client's trachea, especially if the client has poor oral hygiene or respiratory secretions.

Choice A Reason:Notifying the prescriber is essential, but it is secondary to obtaining objective data. The nurse must first secure timely laboratory results to report concrete values. Immediate notification without current coagulation data delays informed decision-making about reversal, dosing changes, or additional interventions.

Choice B Reason: Monitoring for signs of bleeding is important but not the priority action for the nurse because it does not address the cause of the problem or prevent further harm. The nurse should monitor the client's vital signs, hemoglobin, hematocrit, and urine output, as well as check for any signs of bleeding, such as bruising, petechiae,

hematuria, hematemesis, melena, or epistaxis.

Choice C Reason: Completing an adverse occurrence report is important but not the priority action for the nurse because it does not provide immediate intervention or treatment for the client. The nurse should complete an

adverse occurrence report after notifying the healthcare provider and implementing appropriate actions. The report should include the details of the error, such as the time, dose, route, and name of the medications involved, as well as the client's response and outcome.

Choice D Reason:Rapidly measuring PT/INR and aPTT provides objective evidence of anticoagulation level after dual therapy. These results directly influence urgent clinical decisions, such as holding anticoagulants, administering reversal agents, or preparing for interventions to control bleeding, making this the highest‑priority action.