A nurse enters a client's room and finds the client on the floor. Which of the following actions should the nurse take first?

The nurse should include the statement "Delegation permits a designated individual to meet a goal on your behalf" in the teaching. This is because delegation allows the nurse to assign tasks to an AP who has the appropriate skills and knowledge to complete them, while still maintaining accountability for the outcome of the task.
Option A is incorrect because accountability for a delegated task remains with the delegator, not the AP.
Option C is incorrect because discharge teaching activities for clients cannot be delegated to an AP as they require nursing judgment and assessment.

Option D is incorrect because it is important for the nurse to follow up on delegated tasks even if the AP has completed them before to ensure that they have been completed correctly and that the client's needs have been met.

The correct answer is Choice C.

Choice A rationale: A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg. This client is stable. The blood pressure is within normal range, indicating that the client is not experiencing a transfusion reaction, which could cause hypotension. Therefore, this client is not the highest priority.

Choice B rationale: A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10. While pain management is an important aspect of client care, a pain level of 4 indicates that the client’s pain is manageable. Therefore, this client is not the highest priority.

Choice C rationale: A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 mL/hr. This client is showing signs of oliguria, which could indicate a serious complication such as hypovolemia or acute kidney injury. This client is the highest priority because these complications can lead to further serious issues such as shock or end-organ damage if not addressed promptly.