A nurse is caring for a client who has end-stage lung cancer.

The client has a decreased level of consciousness, extreme shortness of breath, and a respiratory rate of 40/min. The client's family member states to the nurse, "My sibling doesn't have any advance directives.
Can they still receive palliative sedation?"

Which of the following statements should the nurse include when speaking with the client's family?

Choice A rationale

Efficient peripheral perfusion is critical for pulse oximetry accuracy because the device relies on detecting pulsatile arterial blood flow. A capillary refill time of less than 2 seconds indicates adequate local circulation, ensuring that the sensor can effectively distinguish between oxygenated and deoxygenated hemoglobin. If perfusion is sluggish, the infrared light may not accurately detect the pulse, leading to false low readings or an inability to obtain a consistent waveform during the assessment process.

Choice B rationale

Most modern pulse oximeters provide a stable reading within 10 to 30 seconds after placement once a consistent pulse signal is detected. Waiting a full minute is generally unnecessary and could delay clinical decision-making in acute situations. The nurse should observe the waveform or signal strength indicator to ensure the reading is reliable. Prolonged waiting does not improve accuracy if the initial signal is already high quality, and it may lead to inefficiencies in nursing workflow.

Choice C rationale

Placing the sensor probe on the same extremity as a blood pressure cuff is contraindicated because the inflation of the cuff temporarily occludes arterial blood flow. This occlusion results in a loss of the pulsatile signal required by the oximeter, leading to inaccurate readings or triggering false alarms. To ensure continuous and accurate monitoring, the nurse should use the opposite limb or a site unaffected by the periodic pressure exerted by the blood pressure measurement device.

Choice D rationale

Sensor site rotation is a vital nursing intervention to prevent skin breakdown and pressure-related injuries, but the frequency should be higher than every 8 hours. Standard clinical practice typically requires relocating the sensor every 2 to 4 hours, especially in patients with fragile skin or poor circulation. Extended placement at a single site increases the risk of localized ischemia and thermal injury from the light source, so an 8-hour interval is considered too long for safety.

Choice A rationale

Assessment is a core part of the nursing process that requires clinical judgment and specialized knowledge. The registered nurse must evaluate the nature, intensity, and location of pain to develop an appropriate plan of care. Unlicensed personnel lack the training to interpret physiological and psychological data. Delegating assessment can lead to missed complications or delayed treatment. Therefore, the nurse remains responsible for all patient assessments.

Choice B rationale

Obtaining vital signs is a routine, technical task that can be safely delegated when the patient is physiologically stable. The assistant must be trained in the procedure and know the parameters to report. The nurse retains responsibility for interpreting these values in the context of the patient's condition. Normal adult vital signs typically include a heart rate of 60 to 100 beats per minute and a respiratory rate of 12 to 20 breaths.

Choice C rationale

Discharge teaching involves complex education regarding medications, activity restrictions, and follow-up care tailored to the patient's specific needs. This task requires the pedagogical skills and clinical expertise of a registered nurse. Unlicensed staff are not qualified to provide formal education or evaluate the patient's readiness for discharge. Effective teaching ensures patient safety and reduces readmission rates. The nurse must document the patient's understanding and any barriers to learning encountered during the session.

Choice D rationale

Dressing changes for surgical or complex wounds often require sterile technique and the ability to assess wound healing or signs of infection. These tasks are generally outside the scope of unlicensed personnel unless the wound is simple and chronic. The nurse must inspect the site for redness, edema, or purulent drainage. Improper technique by untrained staff can introduce pathogens, leading to sepsis or delayed recovery. Clinical judgment is necessary during the procedure.

Choice E rationale

Assisting with activities of daily living is a fundamental role of unlicensed personnel. This includes helping patients with bathing, dressing, and feeding to meet self-care deficits. These tasks are repetitive and do not require the complex clinical judgment of a licensed professional. By delegating these duties, the nurse can focus on higher-level clinical interventions. However, the nurse must still supervise and ensure the patient's safety and comfort are maintained during these activities.

Choice F rationale

Phlebotomy is a technical skill that many facilities allow trained unlicensed personnel to perform once they have demonstrated competency. This involves the collection of blood samples for laboratory analysis while maintaining aseptic technique. While it requires precision, it does not involve the diagnostic assessment or clinical reasoning reserved for the nurse. The nurse must ensure the samples are labeled correctly and sent to the lab promptly. Success depends on following strict facility protocols.