A nurse is caring for a client and using active listening skills. Which of the following actions should the nurse take?

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. Place the head of the client's bed flat:

This action is not appropriate because lying flat can worsen dyspnea in many cases. It can restrict lung expansion and make breathing more difficult. Instead, the nurse should elevate the head of the bed or position the client in a semi-Fowler's or high-Fowler's position to facilitate easier breathing.

B. Perform nasotracheal suctioning for the client:

Nasotracheal suctioning is not indicated for dyspnea unless there is a specific medical reason, such as airway obstruction or excessive secretions. Performing suctioning without a clear indication can cause discomfort and may not address the underlying cause of dyspnea.

C. Increase the heat in the client's room:

Adjusting the room temperature is generally not a direct intervention for dyspnea. While maintaining a comfortable environment is important, dyspnea is usually managed through other means such as medication and positioning.

D. Administer an opioid narcotic to the client:

This is the most appropriate action among the choices provided. Opioid narcotics, such as morphine, are commonly used to alleviate dyspnea in end-of-life care. They help reduce the sensation of breathlessness, calm respiratory distress, and improve overall comfort for the client.