A nurse in reviewing the laboratory data on a client who has a new prescription for heparin for treatment of a pulmonary embolism. Which of the following data should the nurse report to the provider?

A. Stage 2: A Stage 2 pressure ulcer is characterized by partial-thickness skin loss, which may present as an open wound or blister. The presence of black eschar indicates that the skin loss is deeper than what is described in Stage 2.

B. Stage 3: A Stage 3 pressure ulcer involves full-thickness skin loss, which may extend into the subcutaneous tissue but does not involve bone or muscle. However, the presence of black eschar suggests that the wound cannot be accurately assessed because the base is not visible.

C. Stage 1: A Stage 1 pressure ulcer is identified by intact skin with non-blanchable redness. Since there is a broken skin and black eschar in this case, it cannot be classified as Stage 1.

D. Unstageable: A wound is considered unstageable when there is full-thickness skin loss and the base of the wound is covered with necrotic tissue (eschar) or slough, making it impossible to determine the depth and true stage of the ulcer. In this scenario, the black eschar covering the base of the wound prevents accurate staging, so the wound is classified as unstageable.

A. Bathe a client who had an amputation 2 days ago: This task can be delegated to assistive personnel (AP). APs are trained to assist with activities of daily living, including bathing, under the supervision of nursing staff. The nurse should ensure that the AP is aware of any special considerations related to the client's recent amputation.

B. Review a low-sodium diet for a client who has hypertension: This task should not be delegated to APs, as it requires nursing knowledge and understanding to educate the client effectively. Discussing dietary modifications involves assessing the client's understanding and providing education, which falls under the nursing scope of practice.

C. Feed a client who had a stroke 3 months ago: This task can be delegated to APs, provided that the client is stable and the AP has been trained to assist clients with feeding. However, the nurse should assess the client's swallowing ability and any specific precautions related to the stroke before delegating this task.

D. Explain oral hygiene to a client receiving chemotherapy: This task should not be delegated to APs because it involves providing specific education and instructions regarding oral care, which requires nursing judgment and knowledge about the implications of chemotherapy on oral health.

E. Assist a client to ambulate using a gait belt: This task can be delegated to APs. Assisting with ambulation is within the scope of practice for APs, especially when proper techniques and safety measures, such as using a gait belt, are followed. The nurse should ensure that the AP has received appropriate training to assist with ambulation safely.