A nurse is caring for a preschooler who is in an acute care facility. Which of the following actions should the nurse take?

C. Obtain a client's vital signs every 4 hr:
This task can typically be delegated to assistive personnel (AP) who have been trained and deemed competent in measuring vital signs. Routine monitoring of vital signs, such as temperature, pulse, respirations, and blood pressure, is within the scope of practice for AP and does not require the specialized skills of a licensed nurse.

D. Record a client's intake after each meal:
Assistive personnel can be delegated the task of recording a client's intake after each meal. This involves documenting the amount and type of food and fluids consumed by the client. While assessment of intake may involve some judgment, AP can be trained to perform this task accurately and consistently.

E. Transfer a client to physical therapy:
Assistive personnel can assist with transferring clients to physical therapy sessions. This may include tasks such as assisting clients into a wheelchair or onto a stretcher and accompanying them to the therapy area. While ensuring client safety during transfers is crucial, AP can perform these tasks under the direction and supervision of licensed nursing staff or physical therapists.

A. Instruct a client on the use of an incentive spirometer:
Teaching clients how to use medical equipment, such as an incentive spirometer, typically requires specialized knowledge and skills that fall within the scope of practice of licensed nursing staff. Therefore, this task should not be delegated to assistive personnel.

B. Insert an NG tube for a client who requires enteral feedings:
Inserting an NG tube is a specialized nursing skill that requires training, expertise, and an understanding of anatomy, proper technique, and potential complications. This task should only be performed by licensed nursing staff, such as registered nurses (RNs) or licensed practical nurses (LPNs), who have received appropriate education and training.

A. The client's heart rate increases by 10/min: An increase in heart rate upon changing positions may occur as a compensatory mechanism to maintain blood pressure, but it is not indicative of orthostatic hypotension. Orthostatic hypotension is characterized by a decrease in blood pressure upon assuming an upright position.
B. The client's systolic blood pressure decreases by 25 mm Hg: Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or more, or a decrease in diastolic blood pressure of 10 mm Hg or more, within 3 minutes of standing up from a supine position. Therefore, a decrease in systolic blood pressure by 25 mm Hg upon changing positions is consistent with orthostatic hypotension.
C. The client's diastolic blood pressure increases by 10 mm Hg: Orthostatic hypotension typically involves a decrease in both systolic and diastolic blood pressure upon assuming an upright position. An increase in diastolic blood pressure is not consistent with orthostatic hypotension.
D. The client reports heart palpitations: Heart palpitations may occur due to various reasons, such as anxiety or cardiac arrhythmias, but they are not specific to orthostatic hypotension. While orthostatic hypotension may cause symptoms like dizziness or lightheadedness, heart palpitations are not typically associated with this condition.