A nurse is admitting a client who has not completed an advance directive. What is the nurse's priority action?

A. Assess the client's ability and assist with tasks they cannot perform: Individualized assessment allows the nurse to determine which hygiene activities the client can safely perform and where assistance is needed. This approach promotes independence, preserves dignity, and prevents complications such as skin breakdown. It aligns with patient-centered care and postoperative recovery principles.

B. Focus only on oral hygiene as it is the most important aspect of personal care: Oral hygiene is important, but neglecting other aspects such as skin care, perineal care, and bathing increases the risk of infection and impaired comfort. Comprehensive hygiene is necessary for overall health. Limiting care to one area is inadequate.

C. Encourage the client to perform all hygiene tasks independently: While independence is encouraged, recent surgery and limited mobility may make some tasks unsafe or impossible. Forcing independence can increase fatigue, pain, or risk of injury. Nursing care should balance support with autonomy.

D. Provide full assistance with hygiene tasks without involving the client: Performing all hygiene tasks without involving the client reduces independence and can negatively affect self-esteem. Participation promotes mobility, circulation, and a sense of control. Total care is not indicated unless the client is completely dependent.

A. Set a goal to maintain blood glucose levels within normal range: In the planning phase, establishing measurable and achievable goals is the priority. Setting a target for blood glucose guides the development of interventions and provides a benchmark for evaluating the effectiveness of care.

B. Document the patient's blood glucose readings: Documentation is part of the implementation and evaluation phases. While important for tracking trends, it does not establish the direction of care or plan interventions.

C. Teach the patient about carbohydrate counting: Patient education is an intervention that supports achieving the goal, but it cannot be implemented effectively without first defining the desired outcome.

D. Administer insulin as prescribed: Administering insulin is an implementation action. While critical for management, it is guided by the plan and goals set during the planning phase, rather than being the initial planning step.