A nurse has completed the planning step of the nursing process for a client who has an acid-base imbalance. Which of the following steps should the nurse take next?

Explanation:

A. "Delegate tasks such as vital signs regardless of the client's condition."

This statement is incorrect because delegation should be based on the complexity of the task, the client's condition and stability, the competence of the delegatee, and other factors. Vital signs are critical assessments that often require the direct involvement of a licensed nurse, especially when there are changes in the client's condition or if the client is unstable.

B. "Delegate simple tasks prior to evaluating the client's condition."

This statement is incorrect because delegation should not occur based solely on the simplicity of the task. Instead, the nurse should evaluate the client's condition first, assess the complexity of care required, and then delegate tasks accordingly. The client's needs, stability, and safety should guide the delegation process.

C. "Observe delegated tasks directly during task performance."

While direct observation of delegated tasks is important, it may not always be feasible or necessary for every task. Nurses should use their judgment to determine the level of supervision required based on factors such as the complexity of the task, the delegatee's experience and competence, and the client's condition. Direct observation may be necessary for more complex or critical tasks, but for routine and low-risk tasks, periodic checks and effective communication with the delegatee can suffice.

D. "Delegated tasks require follow-up to ensure compliance."

This statement is correct. Follow-up is essential to ensure that delegated tasks were performed correctly, safely, and in accordance with the client's care plan. It allows the nurse to verify task completion, assess the client's response if applicable, address any issues or concerns that arise, and provide feedback and guidance to the delegatee. Follow-up also helps maintain accountability and quality of care.

Explanation:

A. Incorporate the treatment into the client's care:

Once the nurse has determined whether the client's grieving is healthy or complicated, they can integrate appropriate treatments and interventions into the client's care plan. Treatment options may include counseling, therapy, support groups, medication (if indicated), and holistic approaches to address physical, emotional, and spiritual aspects of grief.

B. Develop client-specific goals and outcomes:

Collaborating with the client, the nurse establishes client-specific goals and outcomes related to grief management and coping. These goals should be realistic, measurable, and aligned with the client's needs and preferences. Examples of goals may include improving coping skills, reducing emotional distress, fostering acceptance, and promoting resilience.

C. Determine whether coping strategies were successful:

Throughout the care process, the nurse continuously evaluates the effectiveness of coping strategies implemented to support the client in managing grief. Assessment of coping strategies involves monitoring the client's emotional state, functional status, coping skills utilization, and progress toward achieving established goals and outcomes. Adjustments to the care plan may be made based on the assessment findings.

D. Establish whether the client's grieving is healthy or complicated:

This step involves assessing the client's grief to determine whether it is a normal, healthy response to loss or if it has become complicated, characterized by intense, prolonged, or dysfunctional grief reactions. Assessing the client's grief status is crucial for tailoring appropriate interventions and support.