Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an assistive personnel (AP)?

The correct answer is choice B: "This is a procedure that does not require written informed consent."

Choice B rationale: Informed consent is typically required for invasive procedures, surgery, or treatments that carry significant risks. While inserting an indwelling urinary catheter is considered an invasive procedure, it is generally not a procedure that requires written informed consent. Nurses often have standing orders or standardized procedures in place for catheterization, and consent is usually implied or obtained verbally.

Choice A rationale: Although providers prescribe procedures, consent is still necessary in many cases. However, as mentioned above, written informed consent is not typically required for urinary catheter insertion due to its routine nature in medical care.

Choice C rationale: Discussing the issue with the charge nurse is unnecessary since written informed consent is not generally required for this procedure. The nurse should instead focus on educating the family about standard hospital practices.

Choice D rationale: Asking the family to sign the informed consent form at this point is not appropriate, as it implies that the procedure should not have been performed without written consent. Additionally, urinary catheterization does not typically require written informed consent, so asking them to sign a form could create confusion or unnecessary concern.

Choice A rationale:

A client who is scheduled for a tubal ligation in 2 hr and is crying. Rationale: While the emotional well-being of this client is important, the absence of pulse in the right foot of the client in choice B indicates a potentially critical vascular issue that requires immediate attention.

Choice B rationale:

A client who has peripheral vascular disease and has an absent pulse in the right foot. Rationale: The correct choice. An absent pulse in a client with peripheral vascular disease suggests compromised blood flow and potential tissue ischemia. This is a critical situation that requires urgent intervention to prevent further complications.

Choice C rationale:

A client who has type 1 diabetes mellitus and needs the first dressing change for an ulcer. Rationale: While dressing changes are important, they are not as time-sensitive as addressing compromised blood flow and potential tissue damage seen in choice B.

Choice D rationale:

A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38°C (100.4°F). Rationale: Although an elevated temperature can be concerning, the absence of a pulse in a peripheral vascular disease client (choice B) takes precedence as it suggests a more immediate threat to the client's limb and overall health.