A nurse is caring for a client who is angry and states, "The doctor gave me the wrong information. I was lied to!" Which of the following responses by the nurse is appropriate?

A. Check a client's peripheral IV site for redness or swelling.
This task involves assessing the client's IV site for signs of complications. While it requires observation and reporting, it may involve some interpretation and judgment. This task is better suited for a licensed nurse.

B. Measure the intake and output of a client who has received furosemide.
Measuring intake and output is a routine task that involves quantifying the fluids a client consumes and eliminates. This is a task that can be appropriately delegated to an assistive personnel (AP) under the supervision and direction of the nurse.

C. Reinforce teaching with a client about crutch-gait walking.
Teaching requires a level of education, explanation, and clarification that goes beyond routine tasks. This is typically a nursing responsibility and should not be delegated to an AP.

D. Assess the pain level of a client who has received acetaminophen.
Pain assessment involves subjective information, and determining the appropriate response may require clinical judgment. This task is better suited for a licensed nurse.

Choice A Reason:

Avoid entering the client's room unless requested during the night is inappropriate. While minimizing entries can reduce disruptions, it's important for the nurse to perform necessary checks and care interventions. Avoiding the room completely might compromise the client's safety or care.

Choice B Reason:

Turn off alarms on bedside monitoring equipment is inappropriate. Disabling alarms can jeopardize patient safety as these alarms often indicate critical changes in the client's condition. Adjusting alarm settings or investigating if noise levels can be reduced without compromising safety would be more appropriate.

Choice C Reason:

Conduct staff communications away from the client's room is appropriate. This intervention helps minimize noise levels near the client's room, creating a quieter environment conducive to sleep. Staff conducting communications away from the room reduces unnecessary disturbances that might affect the client's rest.

Choice D Reason:

Turn on the client's TV to distract from hallway noise is inappropriate. Introducing more noise, such as from a TV, might not effectively address the issue of sleep disturbance due to external noise. Additionally, it's essential to respect the client's preferences, and some may prefer a quiet environment for sleep rather than additional noise from a TV.