Which client has the greatest need for special mouth care?

This would help the client to feel valued, respected and involved in their own care, which can enhance their self-esteem.

Choice A is wrong because adding a nursing diagnosis of lowered self-esteem to the care plan does not address the underlying causes of the problem or provide any interventions to improve it.

It may also label the client and make them feel worse.

Choice B is wrong because giving praise for every decision the client makes is not realistic or sincere.

It may also undermine the client’s confidence and autonomy by implying that they need constant approval from others.

Choice D is wrong because modeling competent care for the client does not necessarily help them to maintain their self-esteem.

It may even make them feel inadequate or dependent on the nurse.

Emptying the urine drainage bags at least once per shift is a task that can be delegated to unlicensed assistive personnel (UAP) assigned to a cardiac surgery unit.

This task does not require assessment, teaching, or evaluation skills that are beyond the scope of practice of UAP.

Choice A is wrong because teaching a client how to use a pillow to support an incision when coughing requires education and evaluation skills that are only within the scope of practice of licensed nurses.

Choice B is wrong because checking the pedal pulses of bed-bound clients requires assessment skills that are only within the scope of practice of licensed nurses.

Pedal pulses are important indicators of peripheral circulation and vascular status.

Choice C is wrong because ambulating the first-day postoperative clients requires assessment and evaluation skills that are only within the scope of practice of licensed nurses.

First-day postoperative clients may have complications such as bleeding, infection, or hypotension that need to be monitored by a nurse.