The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. Which client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.).

Choice A rationale:

The risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.

Choice B rationale:

Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.

Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.

Choice C rationale:

Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.

Choice D rationale:

Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.

The correct answer is choice A: Record the findings and report the symptoms to the charge nurse.

Choice A rationale:

The practical nurse (PN) should first record the client's findings, including the progressively decreasing appetite, increased daytime bed hours, and refusal to participate in planned activities. This documentation is essential for accurate communication and continuity of care. After recording the findings, the PN should promptly report the symptoms to the charge nurse. Reporting allows for timely intervention and assessment by the charge nurse or other healthcare providers to address the client's issues effectively.

Choice B rationale:

Asking family members to visit more often is not the best action to take in this situation. While family support is important, the client's symptoms suggest possible underlying health concerns that need professional evaluation and management. Relying solely on increased family visits might delay appropriate healthcare interventions.

Choice C rationale:

Motivating the client by offering their favorite foods as a prize might not be appropriate at this stage. The client's decreased appetite and refusal to participate in activities could be indicators of underlying health issues that need to be addressed first. Moreover, encouraging unhealthy eating habits as a "prize”. could be counterproductive to the client's well-being.

Choice D rationale:

Withholding medications that may cause side effects is not a suitable action without consulting the healthcare provider responsible for the client's care. Abruptly stopping medications could lead to adverse effects or complications, and it is essential to involve the healthcare team in making decisions about medication management.