A nurse is caring for an adult male client who is alert and oriented x4 on the medical-surgical unit.

In regard to the pain experience, which of the following is correct?

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.

Choice A rationale

Digoxin has a narrow therapeutic index, typically 0.5 to 2.0 ng/mL. Nausea and weakness are classic early signs of digoxin toxicity. Checking vital signs, particularly the apical pulse, is the priority nursing action to assess for bradycardia or dysrhythmias caused by toxic levels. Assessing the physiological status of the client provides immediate data to determine the severity of the situation before proceeding with further interventions or contacting the provider for laboratory testing.

Choice B rationale

Requesting an antiemetic addresses the symptom of nausea but fails to investigate the underlying cause, which is likely digoxin toxicity. Masking the nausea with medication could delay the diagnosis of a potentially life-threatening cardiac complication. In the context of heart failure and digoxin use, any new onset of gastrointestinal distress must be treated as a sign of toxicity until proven otherwise. Assessment of the client's current clinical stability must always precede symptomatic treatment.

Choice C rationale

A dietitian consult is an inappropriate and delayed response to an acute clinical change. While nutritional support is important for chronic congestive heart failure management, the immediate complaints of nausea and weakness suggest a drug-related complication rather than a primary dietary issue. Focusing on nutrition at this moment ignores the urgent safety risk posed by digoxin. The nurse must prioritize assessment of the client's cardiac and neurological status over long-term dietary planning.

Choice D rationale

Suggesting rest before eating is a passive intervention that ignores the diagnostic significance of the client's symptoms. Nausea in a client taking digoxin is a red flag that requires active clinical evaluation. Waiting for the client to rest does not provide the nurse with necessary data regarding heart rate or rhythm stability. The priority is to identify signs of toxicity early to prevent cardiac arrest or severe conduction blocks associated with high digoxin levels.