A client's PaCO2 is abnormal on an ABG report.
What does the nurse suspect as the most likely medical diagnosis?

Choice A rationale

Emptying a Foley catheter bag and reporting the urine volume is a routine task that does not require complex assessment or clinical judgment. Unlicensed care providers are typically trained in this procedure and can accurately measure and report the output to the nurse.

Choice B rationale

Helping a first-time mother achieve a good latch during breastfeeding requires specialized knowledge and assessment skills to ensure proper positioning and infant feeding. This task involves teaching and evaluating, which falls within the scope of nursing practice and should not be delegated to an unlicensed care provider.

Choice C rationale

Assessing the size and quantity of blood clots in a postpartum client's bedpan requires clinical judgment to determine if the findings are within normal limits or indicative of a potential complication. This assessment should be performed by a registered nurse who can interpret the findings in the context of the client's overall condition.

Choice D rationale

Administering medication, including anti-inflammatory drugs, is a nursing responsibility that requires knowledge of pharmacology, potential side effects, and client assessment. Medication administration should not be delegated to unlicensed care providers. .

Choice A rationale

Playing music chosen by the client can promote relaxation by providing a familiar and comforting auditory stimulus. Music can help to reduce anxiety and create a calming environment, thus minimizing sensory overload in a client recovering from a stroke in the intensive care unit. This personalized approach respects the client's preferences and can positively influence their emotional state, fostering a more restful atmosphere conducive to healing.

Choice B rationale

Encouraging frequent visitors throughout the day can contribute to sensory overload for a client recovering from a stroke. While social support is important, excessive stimulation from multiple visitors can be overwhelming and disrupt the client's rest and recovery process in the intensive care unit, potentially increasing agitation and hindering relaxation.

Choice C rationale

Sitting in a chair next to the client and talking can be stimulating and may not promote relaxation, especially for a client who has recently experienced a stroke. Depending on the content and tone of the conversation, this interaction could increase sensory input and potentially cause agitation or fatigue rather than fostering a calm and restful environment needed for recovery in the intensive care unit.

Choice D rationale

Turning on the television to the Super Bowl would likely exacerbate sensory overload due to the bright lights, loud noises, and fast-paced visual stimulation. This type of environment is counterproductive to promoting relaxation and can be particularly overwhelming for a client recovering from a stroke in the intensive care unit, potentially increasing anxiety and hindering rest.