A home health nurse is completing a home safety visit for a client who had a cerebrovascular accident (CVA). Which of the following actions should the nurse take?

Delegation in nursing requires assigning tasks based on the Five Rights of Delegation, ensuring patient safety, task complexity, and the skill level of assistive personnel (AP). APs are trained to perform routine, non-invasive, and standardized care activities for stable clients. The nurse retains responsibility for assessment, evaluation, sterile procedures, and clinical judgment. Postmortem care is a task that is standardized, does not require clinical decision-making, and is appropriate for delegation in most care settings.

Rationale:
A. Providing postmortem care is appropriate for delegation to assistive personnel because it involves routine physical care of the deceased body, including bathing, positioning, and preparing the body for family viewing. It does not require assessment, sterile technique, or clinical judgment. The task is structured and can be safely performed by trained APs under nurse supervision.

B. Changing a sterile dressing for a postoperative client is not appropriate for delegation because it requires sterile technique, assessment of the wound, and evaluation for infection or healing progression. These actions require licensed nursing judgment to identify complications such as drainage, dehiscence, or infection. Therefore, it must be performed by a licensed nurse.

C. Performing a gastrostomy feeding, even in a stable client, is generally not delegated to APs because it involves risk for aspiration, tube placement verification considerations, and monitoring for tolerance. Although some settings may allow AP involvement in feeding under specific protocols, initial and ongoing assessment of tube patency and client response requires nursing judgment.

D. Observing patency of an intravenous catheter is a nursing responsibility because it requires assessment of infusion site condition, evaluation for infiltration or phlebitis, and clinical decision-making regarding continuation or discontinuation of therapy. APs are not trained or authorized to assess IV lines or detect complications that require intervention.

Risk-taking behavior in young adults is influenced by lifestyle choices, environmental exposures, and health awareness. This developmental stage often involves experimentation and reduced perception of long-term health consequences. Limiting risk-taking behavior is demonstrated by proactive health-promoting actions and avoidance of known risk factors. Nursing assessment focuses on identifying protective behaviors that reduce the likelihood of chronic disease or injury.

Rationale:
A. Switching from tobacco cigarettes to electronic cigarettes does not eliminate risk-taking behavior because electronic cigarettes still expose the client to nicotine and potentially harmful chemicals. While it may reduce some risks compared to traditional smoking, it is not considered a fully healthy or risk-limiting behavior. The client is still engaging in substance use that carries health consequences.

B. Being exposed to toxic chemicals at work without current harm indicates ongoing occupational risk exposure. Even if no injury has occurred yet, continued exposure without adequate protection or mitigation strategies still represents a risk-taking environment. This statement does not reflect active efforts to reduce risk.

C. Acknowledging stress at work and home without taking action does not demonstrate risk reduction. Chronic stress without coping strategies or intervention can contribute to adverse physical and mental health outcomes. Passive acceptance of stressors reflects lack of protective behavior rather than risk limitation.

D. Acknowledging a family history of diabetes and actively choosing a healthy diet reflects preventive health behavior. This indicates awareness of genetic risk factors and implementation of lifestyle modifications to reduce disease development. In relation to Type 2 diabetes mellitus, dietary control is a key modifiable factor that helps reduce risk and demonstrates proactive health management.