A nurse is admitting a client.

The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply.

A. Assist the client with a partial bed bath: Assisting with personal hygiene is within the scope of practice for assistive personnel (AP). This task does not require nursing judgment or assessment skills, making it appropriate to delegate while ensuring the client’s comfort and dignity are maintained.

B. Measure the client's BP after the nurse administers an antihypertensive medication: Taking vital signs is a standard task that APs can perform. The nurse is responsible for administering the medication and interpreting the results, while the AP can obtain the blood pressure reading and report it promptly to the nurse for assessment of the client’s response.

C. Test the client's swallowing ability by providing thickened liquids: Assessing swallowing is a nursing responsibility because it requires professional judgment to identify signs of aspiration, evaluate dysphagia severity, and implement safe feeding techniques. Delegating this task could risk the client’s safety if aspiration occurs.

D. Use a communication board to ask what the client wants for lunch: Determining the client’s preferences using a communication board requires assessment of cognitive and language abilities and may involve interpreting nonverbal cues. This is a nursing task that involves critical thinking and cannot be safely delegated to an AP.

E. Irrigate the client's indwelling urinary catheter: Catheter irrigation is considered an invasive procedure that carries risks of infection and requires knowledge of sterile technique. This task is within the nurse’s scope of practice and should not be delegated to APs, as improper technique could cause harm.

A. Place the client in a room with negative-pressure airflow: Tuberculosis is transmitted through airborne droplet nuclei that remain suspended in the air for prolonged periods. Negative-pressure isolation rooms (airborne infection isolation rooms) prevent contaminated air from escaping into surrounding areas by ensuring airflow moves into the room rather than out.

B. Wear gloves when assisting the client with oral care: Standard precautions require the use of gloves when there is potential contact with saliva, mucous membranes, or other body fluids. Oral care involves direct exposure to saliva and respiratory secretions, which may contain Mycobacterium tuberculosis. Wearing gloves reduces the risk of cross-contamination.

C. Limit each visitor to 2-hr increments: Tuberculosis infection control focuses on airborne precautions rather than limiting the duration of visits. Visitors should instead be educated about respiratory protection and may be required to wear appropriate masks. Restricting the length of visits does not reduce transmission if appropriate airborne precautions are already in place.

D. Wear a surgical mask when providing client care: Surgical masks do not provide adequate filtration of airborne droplet nuclei that carry Mycobacterium tuberculosis. Healthcare providers must wear a fit-tested particulate respirator such as an N95 mask to filter small airborne particles. Surgical masks are primarily designed to prevent droplet spread from the wearer.

E. Use antimicrobial sanitizer for hand hygiene: Hand hygiene is a fundamental infection prevention measure even though TB is not primarily transmitted by contact. Alcohol-based hand sanitizers or antimicrobial handwashing reduce the spread of other microorganisms and prevent indirect transmission via contaminated surfaces or hands.