The practical nurse (PN) is completing a focused assessment on a client who is prescribed oxygen at 3 liters per minute by nasal cannula. Which assessment finding by the PN requires immediate action?

Choice A rationale:

Procure platelet products from the blood bank. Rationale: Procuring platelet products from the blood bank is a specialized task that requires specific training and authorization. It should be performed by licensed healthcare providers, such as nurses or physicians, rather than unlicensed assistive personnel (UAP).

Choice B rationale:

Titrate oxygen to the prescribed parameters. Rationale: Titrating oxygen to prescribed parameters requires clinical judgment and assessment skills, which are beyond the scope of practice for UAP. This task should be performed by licensed nurses or respiratory therapists.

Choice C rationale:

Monitor an intravenous infusion rate on an established schedule. Rationale: This is the correct answer. UAP can be trained to monitor intravenous (IV) infusion rates on an established schedule for clients who do not require complex adjustments. It is within their scope of practice to ensure that the IV is running at the prescribed rate and to report any abnormalities or concerns to the nursing staff.

Choice D rationale:

Insert a urinary catheter for an uncomplicated client. Rationale: Inserting a urinary catheter is a specialized nursing procedure that should only be performed by licensed nurses or healthcare providers. It is not within the scope of practice for UAP, even for uncomplicated cases.

Choice A rationale:

Taking out dentures and placing them in a labeled cup (Choice A) is a necessary step to ensure the comfort and dignity of the deceased. It helps maintain the appearance and respect for the deceased person.

Choice B rationale:

Gently closing the eyes (Choice B) is a common practice to provide a more peaceful and natural appearance to the deceased. It also prevents the eyes from remaining partially open, which can be distressing for family members.

Choice C rationale:

Placing a small pillow under the head (Choice C) is done to maintain the natural alignment of the head and neck. This helps create a more lifelike appearance and enhances the comfort of the deceased.

Choice E rationale:

Removing resuscitation equipment from the room (Choice E) is essential for maintaining the dignity of the deceased and creating a more peaceful environment for the family. It also helps prevent any distressing reminders of the resuscitation attempt.

Choice D rationale:

Apply a body shroud (Choice D) is not a common practice in preparing the body for viewing by the family. The use of a body shroud may vary based on cultural or religious preferences, but it is not a standard procedure in many healthcare settings.