A nurse is assessing a client's pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?

Rationale:
A. Ask an experienced nurse to assist with the procedure: Seeking assistance from an experienced nurse promotes patient safety and supports proper skill development. The newly licensed nurse can observe, perform the procedure under supervision, and ensure that the client receives competent care while staying within professional practice boundaries.

B. Delegate the task to an assistive personnel: Tracheal suctioning is a sterile and invasive procedure that requires nursing judgment and assessment, which are outside the scope of practice for assistive personnel.

C. Identify that the task is in the scope of RN practice and perform the suctioning: Although tracheal suctioning is within an RN’s scope, the nurse should not perform it independently without adequate training or supervision.

D. Refuse to take the assignment: Refusing the assignment entirely is inappropriate because the nurse has a duty to provide care within their level of competence. Instead, the nurse should seek guidance and supervision to safely complete the procedure.

Rationale:
A. Obtaining the initial assessment of assigned clients: The initial assessment requires nursing judgment and clinical decision-making, which are within the scope of practice of a registered nurse only. It involves data interpretation and establishing a baseline for care, tasks that cannot be delegated to assistive personnel.

B. Educating a client and family members on home care: Client and family teaching requires specialized nursing knowledge to ensure understanding and accuracy. This task involves evaluating learning needs and reinforcing critical information, responsibilities that cannot be legally delegated to assistive personnel.

C. Changing a nonsterile dressing: Assistive personnel can safely perform nonsterile procedures such as changing a clean dressing under the supervision of a nurse. This task involves routine care that does not require nursing judgment, making it appropriate for delegation.

D. Interpreting a client's diagnostic laboratory results: Interpretation of laboratory data involves analysis, clinical reasoning, and the ability to make informed nursing decisions. These actions fall strictly within the nurse’s professional scope of practice and cannot be delegated to assistive personnel.