A client self-medicated with 6 tablespoons of cough medicine prior to coming to the emergency room.

How many mL did the client take? . . .

Choice A rationale

Client 1 presents with stable vital signs. A temperature of 97.8 F, pulse of 66 bpm, respiratory rate of 14, and blood pressure of 122/72 mmHg are all within normal limits. An oxygen saturation of 97 percent is also excellent. This client is physiologically stable and does not require immediate intervention. The nurse should prioritize clients with abnormal respiratory parameters or signs of hypoxia over those who are maintaining normal homeostatic values and adequate oxygenation.

Choice B rationale

Client 2 has vital signs that are mostly within normal ranges. The temperature of 98.8 F and pulse of 82 are normal. A respiratory rate of 16 is ideal. The blood pressure of 130/62 mmHg shows a slightly widened pulse pressure but is not acutely concerning. The pulse oximetry of 95 percent is within the acceptable range for most adults. This client is stable and does not exhibit the acute respiratory distress seen in other potential candidates.

Choice C rationale

Client 3 is the priority because they are showing signs of respiratory distress and hypoxia. A respiratory rate of 28 breaths per minute is tachypneic (normal is 12 to 20), and an oxygen saturation of 90 percent is below the standard target of 95 to 100 percent. This indicates the client is struggling to maintain oxygenation and requires immediate assessment, potential oxygen therapy, and further diagnostic evaluation to prevent further respiratory failure or cellular hypoxia and related complications.

Choice D rationale

Client 4 demonstrates very stable vital signs. A temperature of 97.2 F, pulse of 70, and respiratory rate of 14 are normal. A blood pressure of 120/80 mmHg is the textbook definition of a normal reading. An oxygen saturation of 100 percent indicates perfect hemoglobin saturation. There is no clinical reason to see this client before Client 3, who is currently experiencing significant respiratory compromise and requires urgent nursing and possibly medical intervention.

Choice A rationale

Assistive personnel are trained to observe and report basic physical safety parameters for clients. Checking the position of a client in soft wrist restraints involves verifying that the client is comfortable and that the restraints are not visibly obstructing circulation or causing skin irritation. This task does not require clinical assessment or nursing judgment, provided the nurse has already performed the initial assessment and continues to monitor the client according to facility policy.

Choice B rationale

Sitting with a client who is no longer in the acute phase of withdrawal is a task appropriate for assistive personnel. Withdrawal symptoms from alcohol usually peak within 48 to 72 hours and subside by day five. The AP can provide companionship and safety monitoring for a stable client who is past the high-risk window for seizures or delirium tremens. This task involves observation rather than active medical intervention or complex clinical evaluation by the nurse.

Choice C rationale

Assessing a client for exhaustion requires professional nursing judgment and a deep understanding of the physiological and psychological impact of hypomania. The nurse must evaluate vital signs, mental status, and physical stability to determine if the client is at risk for cardiovascular collapse or other complications. This level of clinical assessment cannot be delegated to assistive personnel because it involves interpreting subjective and objective data to formulate a specific plan of care.

Choice D rationale

Accompanying a stable client to a therapy session is a routine task that falls within the scope of practice for assistive personnel. The AP ensures the client reaches their destination safely and remains supervised during transport. Since the client has depression but is stable enough for occupational therapy, this activity focuses on mobility and safety rather than complex psychiatric intervention. It allows the nurse to prioritize higher-level tasks while ensuring the client is supported.

Choice E rationale

Setting limits with a client who is experiencing mania involves therapeutic communication techniques and behavioral management strategies that require professional nursing expertise. Clients with mania may be impulsive, aggressive, or intrusive, requiring the nurse to use clinical judgment to de-escalate situations and maintain a therapeutic environment. This is an intervention based on the nursing process and psychological theory, making it inappropriate for delegation to assistive personnel who lack advanced training.