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Mark the chart with client's request for no heroic measures: While it's essential to document the client's advance directives, this task is administrative and should occur after a complete clinical handoff. It does not, by itself, ensure continuity of comprehensive care.

Reassure the client that the client's child will be allowed to visit: Emotional support is important, but logistical or emotional reassurance without fully understanding the client's current condition, preferences, and care needs may miss critical aspects of transitional care.

Provide the client written information about end-of-life care: Offering educational material is helpful but not a priority at the time of transfer. The nurse first needs a clear clinical picture and context to provide care tailored to the client's stage, goals, and comfort.

Place an indwelling urinary catheter and institute strict intake and output measurements: Monitoring fluid balance is important in cardiac clients, but it is not the immediate priority during an acute chest pain episode suggestive of myocardial infarction.

Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema: Assessing perfusion is relevant, but it is secondary to initiating urgent interventions aimed at reducing cardiac damage.

Secure client consent for coronary angiography and percutaneous coronary intervention: Consent may be needed later, but immediate medical stabilization, including aspirin administration, takes priority before diagnostic or interventional procedures.

Neurology unit supervisor: While the supervisor manages staffing and operations in the neurology unit, they are not typically responsible for overseeing individual patient care coordination, especially outside their unit.

Risk management nurse: This nurse addresses issues related to legal concerns, safety events, and liability, not clinical progression or coordination of care. Their role is reactive and focused on adverse event analysis.

Adult nurse practitioner: An adult NP may be involved in clinical assessment and treatment decisions, but care coordination is not their primary responsibility. Their focus is on direct patient care rather than the broader logistical planning of services and follow-up.

Encourage him to go to the nurse's station and talk with another nurse: Redirecting may appear dismissive and does not help reinforce boundaries. It may also escalate the client’s behavior if he feels ignored or shuffled around.

Introduce him to the newly admitted client and ask him to join in the conversation: Involving a client with antisocial traits in another’s admission may be inappropriate and intrusive. It risks violating the new client’s privacy and could create discomfort or safety concerns.

Put his behavior on extinction (do not acknowledge it) and continue talking with the newly admitted client: Ignoring the behavior entirely can be perceived as disrespectful or provoke escalation. Structured, assertive communication is more effective than silence.

Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus: Education is important for long-term infection control, but the immediate priority is the nurse's own protection before interacting with the client.

Explain to the client to inform others that they may have been potentially exposed in the last 14 days: This is part of contact tracing and public health responsibility but should come after the client is tested and isolated appropriately.

Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility: While important for facility infection control, this step follows the nurse’s initial action of donning PPE and safely assessing and testing the client.

Feelings of disorientation: Disorientation can occur with heroin use but is often transient and managed symptomatically. While relevant, it is less critical than other long-term safety risks when forming an initial care plan.

Undiagnosed social anxiety symptoms (SAD): Social anxiety may contribute to substance use, but it requires formal diagnosis and long-term intervention. Immediate concerns like suicide risk take precedence in acute care planning.

Family history of schizophrenia: Genetic predisposition to schizophrenia is relevant for long-term mental health surveillance, but it does not demand urgent intervention during an initial admission for heroin use unless psychotic symptoms are present.

Administer a half dose now: Giving a partial dose without knowing how much was absorbed can lead to dosing errors. Digoxin has a narrow therapeutic range, making careful dosing essential.

Give another dose: Re-administering the full dose risks digoxin toxicity, particularly in infants. Since some of the medication may have been absorbed, it is unsafe to give another full dose without medical supervision.

Mix the next dose with food: Digoxin should not be mixed with food, as this can affect its absorption. Dosing should be consistent and based on exact measurements without altering the route or method.

Monitor the client's current white blood cell count (WBC): While WBC can indicate infection, this is not an immediate concern at four hours post-op, where serosanguineous drainage is more likely related to surgical bleeding than infection.

Withhold next scheduled dose of low molecular weight heparin: Anticoagulants are used to prevent deep vein thrombosis postoperatively and should not be withheld unless bleeding is active or confirmed excessive, which has not yet been determined.

Confirm that the continuous passive motion device is intact: While the device supports joint mobility, it is unrelated to assessing or managing wound drainage, which is the priority concern in this situation.

Administer an antiemetic to prevent vomiting: Vomiting can increase intraocular pressure, but administering an antiemetic is not the priority when the client reports new acute deep eye pain, which may indicate a serious complication.

Apply bilateral eye shields to reduce photosensitivity: Eye shields are helpful for protection postoperatively, but photosensitivity is not the focus here; acute deep eye pain suggests a potentially urgent problem requiring physician evaluation.

Begin postoperative prophylactic antibiotics: Antibiotics help prevent infection but do not address the sudden onset of deep eye pain, which could indicate serious issues like increased intraocular pressure or surgical complications.

Amount of pain control: While it is useful to assess whether the ibuprofen is effectively managing the client’s symptoms, this does not address the potential risks or reasons for the original aspirin use, which could have broader clinical significance.

Dosage of ibuprofen taken: Knowing the dose is important due to risks of overdose or gastrointestinal side effects, but it is secondary to understanding why the client was originally taking aspirin, as that may impact cardiovascular or stroke prevention.

Presence of gastric pain: This is relevant because both aspirin and ibuprofen can cause GI irritation, but assessing symptoms without knowing the purpose of the original therapy may delay identification of a more critical clinical issue, like missed antiplatelet therapy.

Explain the ELISA test will be needed to confirm the results: The client was already diagnosed HIV-positive six months ago, making a repeat ELISA test unnecessary and irrelevant to addressing the client’s current emotional state.

Inquire about plans to further education: Asking about future education plans may seem dismissive of the client's immediate emotional distress and is not appropriate when the priority is assessing psychological support.

Explore feelings of hope for the future: Encouraging hope is important, but it should be approached after identifying current emotional support systems and immediate needs for mental health intervention.

Record the amount of daily wound drainage: Monitoring wound drainage is important to track healing and detect infection, but it is secondary to maintaining fluid and electrolyte balance, which can be severely disrupted after bowel surgery.

Assess skin condition and turgor for breakdown: Skin assessment helps monitor hydration and prevent pressure injuries, but this is supportive care. Without addressing fluid replacement first, skin integrity will continue to deteriorate due to systemic dehydration.

Turn every 2 hours around the clock from side-to-side: Repositioning is essential for preventing pressure ulcers but does not address the acute physiological threats posed by fluid loss and instability in the immediate postoperative period.

An older adult who is scheduled for foot amputation due to diabetes complications: This client may require detailed preoperative teaching and complex care planning, which are more appropriate for the RN.

An adult with alcoholism, cirrhosis, and hepatic encephalopathy: This client is at high risk for complications such as altered mental status and requires frequent assessments and critical thinking, best managed by the RN.

An older client who is one day postoperative with a colostomy for colon cancer: Colostomy care and client education may require more advanced assessment and teaching skills, making this assignment more suitable for the RN.

Frequency that the problem occurs: While frequency may influence research focus or clinical interest, it does not determine the quality or applicability of evidence for a specific client's issue.

Past experience with similar problems: Clinical experience is valuable, but evidence-based practice prioritizes current, research-supported data over anecdotal or individual past experiences.

Related personal values: Personal values may affect care delivery but should not override scientifically valid evidence when making clinical decisions based on best practices.

Complete ongoing focused assessments of a client with wrist restraints: While initial assessments must be done by an RN, ongoing focused assessments of restraints can often be delegated to a PN under RN supervision according to facility policies.

Administer PRN oral analgesics to a client with a history of chronic pain: Administering PRN oral medications for stable, chronic conditions is a task that a PN can perform, depending on state regulations and facility protocols.

Transport a client who is receiving IV fluids to the radiology department: Transporting stable clients with IV fluids can be delegated to a UAP if the IV is well-established and there are no expected complications.