A 32 year old client with end stage lung cancer tells the nurse he wants to go home and die. Which of the following is the most important action for the nurse to take?

Choice A rationale

Obtaining a daily weight is a standardized, non-invasive task that falls within the scope of practice for assistive personnel. In heart failure management, monitoring weight is crucial for assessing fluid volume status, where a gain of 2 to 3 pounds in a day or 5 pounds in a week is significant. The nurse remains responsible for interpreting the data and assessing for edema or respiratory distress, but the physical act of weighing is a delegated task.

Choice B rationale

Wound irrigation and dressing changes for a pressure injury require sterile or clean technique, assessment of tissue integrity, and clinical judgment regarding healing progress. These actions are within the professional scope of a licensed nurse and cannot be delegated to assistive personnel. The complexity of evaluating the wound bed for slough, eschar, or granulation tissue requires the advanced training of a registered nurse to ensure appropriate interventions and prevents potential complications or infection.

Choice C rationale

The administration of medications, including oral PRN pain medications, is a licensed nursing responsibility. It involves assessing the patient's pain level, verifying the five rights of medication administration, and monitoring for side effects or therapeutic outcomes. Assistive personnel are not licensed to handle or administer medications in most acute care settings. The nurse must evaluate the effectiveness of the medication and ensure that the dosage is safe based on the patient's current clinical status.

Choice D rationale

Teaching a client how to use an incentive spirometer is a core component of patient education and respiratory assessment. Education requires the nurse to evaluate the client's understanding, demonstrate the correct technique, and assess the client's ability to perform the task effectively to prevent atelectasis. Assistive personnel can encourage a client to use the device once the nurse has performed the initial teaching, but the actual instruction and validation of learning must be performed by the nurse.

Choice A rationale

An increase in the size of the pupils is not an expected finding in an older adult; instead, pupils typically become smaller with age. This condition, known as senile miosis, occurs because the muscles that control the iris weaken. Smaller pupils reduce the amount of light reaching the retina, which can impair vision in dim lighting. Therefore, observing dilated or larger pupils would be an abnormal finding rather than a standard expectation of the aging process.

Choice B rationale

Increased peripheral vision is not expected in older adults, as aging typically results in a gradual narrowing of the visual field. Changes in the retina and the loss of photoreceptor cells often lead to a reduction in the ability to see objects at the periphery. Conditions like glaucoma, which are more common in older populations, can also significantly diminish peripheral sight. Consequently, the nurse would expect a decrease, rather than an increase, in the client's peripheral vision.

Choice C rationale

Increased sensitivity to touch is not a typical finding in the elderly; rather, most older adults experience a decrease in tactile sensitivity. This is due to a reduction in the number of sensory receptors in the skin and changes in the peripheral nervous system. This diminished sense of touch can increase the risk of injury, as the client may not feel pressure or heat as acutely. The nurse should be aware of this reduced sensation during assessments.

Choice D rationale

An increase in cerumen in the ear canal is a common finding in older adults. With age, the cerumen-producing glands atrophy, leading to earwax that is drier and harder. Additionally, the hair in the ear canal becomes coarser, which can trap the wax and lead to impaction. This buildup can cause conductive hearing loss. It is a standard physiological change that nurses frequently observe and manage during the physical assessment of elderly clients.