A nurse is caring for a client who presents to the emergency department.

Exhibits

A nurse is reviewing the client's record. Which of the following client findings indicate the need for further evaluation?
(Select All that Apply.)

Choice A rationale:

Transferring a client to physical therapy is a task that can be safely delegated to an assistive personnel (AP) as long as the client does not have any specific medical restrictions or requires specialized assistance during the transfer. APs are trained to assist with activities of daily living, including transferring clients from one place to another. However, it is essential for the nurse to assess the client's condition and provide clear instructions to the AP to ensure a safe transfer.

Choice B rationale:

Obtaining a client's vital signs every 4 hours is a routine task that can be delegated to an assistive personnel. APs are trained to measure vital signs such as blood pressure, heart rate, respiratory rate, and temperature under the supervision of licensed healthcare providers. Regular monitoring of vital signs is crucial in assessing the client's overall health status and detecting any changes that might require immediate medical attention.

Choice E rationale:

Recording a client's intake after each meal is a task that can be delegated to an assistive personnel. APs can document the amount and type of food and fluids consumed by the client. Monitoring the client's intake is important, especially if the client has specific dietary restrictions, allergies, or medical conditions that require close monitoring of their food and fluid intake.

Choice C rationale:

Instructing a client on the use of an incentive spirometer requires specialized knowledge and assessment of the client's respiratory status. This task should be performed by a licensed healthcare provider, such as a nurse or respiratory therapist, who can properly assess the client's lung function, demonstrate the correct technique, and ensure the client's safety during the process. Delegating this task to an AP could result in improper use of the spirometer, potentially leading to complications or ineffective therapy.

Choice D rationale:

Inserting an NG tube for a client who requires enteral feedings is a complex medical procedure that should be performed by a licensed nurse or healthcare provider with appropriate training and expertise. This procedure carries risks, including the risk of aspiration if not done correctly. Delegating this task to an AP is outside their scope of practice and could jeopardize the client's safety.

Jaw pain in a client taking alendronate, a bisphosphonate, for postmenopausal osteoporosis may be a sign of a rare but serious side effect called osteonecrosis of the jaw (ONJ). Therefore, the nurse should respond by: Report the client's jaw pain to the healthcare provider.

Jaw pain can be an indication of ONJ, a condition characterized by the death of jawbone tissue. It is important to notify the healthcare provider so that further evaluation and appropriate management can be initiated. The healthcare provider will determine the best course of action, which may include referral to a specialist for further assessment and treatment.

Determining how the client is administering the medication is not the immediate concern in this situation. While it is important to ensure that the client is following proper administration instructions for alendronate, addressing the jaw pain takes precedence. Advising the client to gargle with warm salt water twice daily may not be sufficient or appropriate for managing jaw pain related to alendronate use. The client needs a comprehensive assessment by the healthcare provider to determine the cause of the jaw pain and provide appropriate interventions.

Confirming that jaw pain is a common symptom of osteoporosis is not accurate. While osteoporosis can lead to bone pain, jaw pain specifically associated with bisphosphonate use is more likely to be related to ONJ and requires further evaluation and management.