A nurse enters the room of a client who is unconscious and finds that the client's son is reading her electronic medical records from a monitor located at the bedside. Which of the following actions should the nurse take first?

Choice A reason: This is not the correct choice because low pain tolerance is not the most urgent issue to address. The client may experience some pain and discomfort after the surgery, but this can be managed with medication and non-pharmacological interventions. The nurse should educate the client on how to use pain scales, request pain relief, and apply ice packs or heat pads as needed.

Choice B reason: This is not the correct choice because decreased self-esteem is not the most urgent issue to address. The client may have some negative feelings about their appearance or abilities after the surgery, but this can be improved with counseling and support groups. The nurse should encourage the client to express their emotions, focus on their strengths, and seek professional help if necessary.

Choice C reason: This is not the correct choice because limited social support is not the most urgent issue to address. The client may have difficulty coping with the recovery process and the lifestyle changes required after the surgery, but this can be alleviated with community resources and referrals. The nurse should assess the client's social network, provide information on local agencies and organizations, and arrange for home health care or visiting nurses if needed.

Choice D reason: This is the correct choice because inadequate food supply is the most urgent issue to address. The client needs to have access to nutritious and balanced meals to promote healing and prevent complications after the surgery. The nurse should evaluate the client's food security, provide food vouchers or coupons, and connect the client with food banks or meal delivery services.

The correct answer is: B.

Choice A reason:

Suctioning a client's long-term tracheostomy is a complex procedure that involves sterile technique and assessment skills that are beyond the scope of assistive personnel's practice. It requires clinical judgment and the ability to respond to complications, which are responsibilities typically reserved for licensed nursing staff.

Choice B reason:

Using a pain rating scale to monitor a client's pain level is a task that can be delegated to assistive personnel. It involves asking the client to rate their pain on a scale, which does not require clinical judgment or advanced skills. The assistive personnel can then report the pain level to the nurse, who will make decisions regarding pain management.

Choice C reason:

Performing a dressing change on a client's peripherally inserted central catheter (PICC) is not within the scope of assistive personnel. This task requires aseptic technique and knowledge of PICC line management to prevent infection and other complications, which are typically the responsibility of the registered nurse or licensed practical nurse.

Choice D reason:

Instructing a client on self-administration of a tap water enema involves teaching and assessment to ensure the client understands and can perform the procedure safely. This is a task that requires licensed nursing knowledge and skills to educate the client and evaluate their competency.