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Modify the protocol for donning and removing personal protective equipment before entering or leaving the client’s room:Standard precautions should be followed, but the primary emphasis is on airborne precautions due to the potential for airborne transmission of TB. Modifications to donning and removing PPE are not the main focus.

Have staff and visitors wear gowns, masks, and gloves while in the client’s room:
Airborne precautions are more specific for suspected active tuberculosis. While gowns, masks, and gloves may be used for other infectious diseases, the key precaution for TB is a private room with negative pressure ventilation.

Assign the client to a room with other clients who require droplet precautions:Tuberculosis is primarily transmitted through airborne particles, not droplets. Placing the client in a room with droplet precautions is not sufficient to prevent the spread of tuberculosis.

Glucagon:Glucagon is not used as an antidote for heparin overdose. It is typically used to treat severe hypoglycemia.

Vitamin K:Vitamin K is the antidote for warfarin, another anticoagulant, but it is not effective for reversing the effects of heparin.

Calcium:Calcium is not an antidote for heparin. It is more relevant in cases of calcium channel blocker toxicity or hypocalcemia.

Reduces inflammation:This action is more characteristic of anti-inflammatory medications, such as corticosteroids. Expectorants, however, do not primarily reduce inflammation.

Dries mucous membranes:This action is more characteristic of antihistamines or decongestants, which may help reduce nasal congestion by drying mucous membranes. Expectorants have the opposite effect; they promote the thinning of mucus.

Suppresses the urge to cough:This action is associated with antitussive medications, which are cough suppressants. Expectorants, on the other hand, stimulate the removal of mucus and do not suppress the urge to cough

A client who has a prescription for insulin, and his premeal capillary blood glucose was 110 mg/dL, and his post-meal capillary blood glucose is now 160 mg/dL:While changes in blood glucose levels are important to monitor, the described change is not as significant as a sudden drop in blood pressure. The blood glucose levels in this scenario are still within a reasonable range.

A client who reports pain as 4 on a scale of 1 to 10 at 0800 and now reports pain as 6:
Pain management is important, but the change in pain intensity from 4 to 6, while indicating an increase, may not be as urgent as addressing a significant drop in blood pressure. Pain assessment and management can be addressed after stabilizing the client with the acute change.

A client whose wound drainage at 0800 was sanguineous, and now it is serosanguineous:Changes in wound drainage color can be important for assessing the healing process, but a shift from sanguineous to serosanguineous is generally within the expected progression of wound healing. It may not require immediate intervention as compared to a significant drop in blood pressure.

The patient extubated himself:If the patient extubates himself (removes the endotracheal tube), this may result in a low-pressure alarm, not a high-pressure alarm. The low-pressure alarm is triggered when there is a loss of pressure within the ventilator circuit due to disconnection or extubation.

The ventilator tubing may be disconnected:
If the ventilator tubing is disconnected, it is more likely to trigger a low-pressure alarm, indicating a loss of pressure in the ventilator circuit. This is not the primary cause of increased resistance seen with a high-pressure alarm.

The cuff at the end of the endotracheal tube is deflated:A deflated cuff can lead to air leakage around the endotracheal tube but is not the primary cause of increased airway resistance seen with a high-pressure alarm. It may cause a low-pressure alarm if cuff pressure is monitored.

Evaluating changes to a client’s pressure ulcer:Assessing and evaluating changes in a client's condition, including pressure ulcers, involves clinical judgment and interpretation of findings, tasks typically performed by an RN.

Admission assessment of a new client:
Conducting comprehensive assessments, especially for new admissions, requires a higher level of nursing assessment skills and is generally within the scope of practice for an RN.

Scheduling a diagnostic study for a client:The task of scheduling diagnostic studies involves organizational and administrative skills. RNs often handle coordination of care, including scheduling, as part of their responsibilities.

Loop the tubing of the chest tube on the client’s bed:Looping the tubing may create dependent loops that can trap drainage and prevent effective functioning of the chest tube. It can impede the drainage of air or fluid from the pleural space.

Strip the client’s chest tube every 2 hrs:Stripping or milking the chest tube is an outdated practice. It can cause trauma to the tissue surrounding the chest tube and increase the risk of complications, including damage to the lung tissue or tubing.

Tape the connections on the client’s chest tube:Taping the connections on the chest tube is not recommended. It is important to keep connections secure, but taping can make it difficult to quickly identify and address any issues with the chest tube system during monitoring and assessment.

Reassuring the partner of a client who sustained a closed head injury:While providing support and reassurance to family members is important, it is not as urgent as assessing a client with potential signs of a DVT.

Taking a telephone prescription about a client who is to be transferred from PACU:
While obtaining and implementing orders in a timely manner is important, assessing and addressing a potential DVT takes precedence due to the immediate risk to the client's well-being.

Reinforcing a client’s dressing for the surgical site of an above-the-knee amputation:Dressing reinforcement is important for wound care, but it is not as urgently needed as assessing a client with possible signs of a DVT. The assessment of calf pain takes priority.

Right Circumstances:This involves ensuring that the tasks being delegated are appropriate for the circumstances and consistent with the plan of care. The nurse should consider factors such as the client's condition, the complexity of the task, and the stability of the client's health status.

Right Communication:Effective communication is crucial in delegation. This includes clear and concise instructions, expectations, and a feedback loop. The nurse should ensure that communication is understood and acknowledged by both parties involved in the delegation.

Right Person:The right person involves selecting the appropriate individual for the task based on their competence, knowledge, and skills. The nurse must assess the competency of the person being delegated to and ensure that they have the necessary qualifications to perform the assigned task

Metallic taste in the mouth:This is not a typical finding of oxygen toxicity. Metallic taste may be associated with other factors but is not a specific indicator of oxygen toxicity.

Facial flushing:Facial flushing is not a typical finding in oxygen toxicity. It is more commonly associated with other conditions, such as certain allergic reactions or vasodilation.

Periorbital edema:Periorbital edema is not a common manifestation of oxygen toxicity. It is more commonly associated with conditions related to fluid balance or kidney function.