A charge nurse is leading a committee that is revising the policy for client discharge. After developing the initial plan, which of the following actions should the nurse take next?

The correct answer isChoice C.

Choice A rationale:

Instructing a client on how to take their blood pressure is a task that involves providing education to the client on a non-invasive procedure that they can perform independently. However, this task requires a certain level of knowledge and understanding that an assistive personnel (AP) may not possess. Therefore, it is not the best task to delegate to an AP.

Choice B rationale:

Administering subcutaneous medications to a client is a task that requires a high level of skill and knowledge. It involves understanding the medication, its side effects, and the correct administration technique. This is a task that should be performed by a nurse or a healthcare professional with the appropriate training and licensure. Delegating this task to an AP could potentially put the client’s health at risk.

Choice C rationale:

Determining a client’s intake and output is a task that can be delegated to an AP.This task does not require the use of the nursing process and is within the range of function of an AP. It involves measuring and recording the amount of fluid a client consumes and excretes, which is a task that an AP is capable of performing.

Choice D rationale:

Providing a status update to a client’s family member is a task that requires a high level of discretion and understanding of the client’s condition. It involves communicating sensitive information about the client’s health status, which should be done by a nurse or a healthcare professional with the appropriate training and licensure. Delegating this task to an AP could potentially lead to miscommunication or a breach of the client’s privacy.

The correct answer is choice A: Provide information about alternate birth control methods.

Choice A rationale:

The nurse should prioritize providing information about alternate birth control methods to the client who is uncertain about undergoing a tubal ligation. This approach aligns with the principle of informed consent and patient autonomy. By presenting different options, the client can make a well-informed decision about their reproductive health. This ensures that the client's choice is based on a comprehensive understanding of all available alternatives.

Choice B rationale:

While involving the client's partner in the decision-making process can be important, the primary responsibility of decision-making lies with the client. Therefore, asking if the client has discussed the decision with their partner (Choice B) may not directly address the client's uncertainty and need for information about alternative birth control methods.

Choice C rationale:

Emphasizing the benefits of having the procedure (Choice C) might not be appropriate if the client is uncertain about whether it's the right choice for them. This approach may come across as biased and not respectful of the client's ambivalence. Providing unbiased information about all options is a more balanced approach.

Choice D rationale:

Discussing the client's feelings about the procedure (Choice D) is essential but should be done in conjunction with providing information about alternate birth control methods. Addressing the client's emotions without offering alternatives may not fully support the client's decision-making process.