A nurse is collecting data from a 24-month-old toddler during an annual physical examination.
Which of the following findings should the nurse report to the provider?

Transferring the client from the bed to a chair. This is a task that can be delegated to an assistive personnel because it does not require nursing judgment or assessment. The nurse should provide clear instructions and supervise the assistive personnel during the transfer.

Choice B is wrong because checking the client’s surgical dressing for bleeding is a nursing assessment that requires clinical judgment and cannot be delegated.

The nurse should monitor the dressing for signs of infection, drainage, or dehiscence.

Choice C is wrong because determining whether the client has incisional pain is a nursing assessment that requires communication and evaluation skills and cannot be delegated.

The nurse should assess the client’s pain level, location, quality, and duration and administer pain medication as prescribed.

Choice D is wrong because showing the client how to use an incentive spirometer is a nursing intervention that requires teaching and evaluation skills and cannot be delegated.

The nurse should instruct the client on how to use the device to promote lung expansion and prevent atelectasis.

Obturator.

An obturator is a device that is inserted into the tracheostomy tube to guide it through the stoma and prevent tissue damage. It should be removed after the tube is inserted and kept near the bedside in case of accidental decannulation.

Choice A is wrong because povidone-iodine is an antiseptic solution that is not routinely used for tracheostomy care. It can cause skin irritation and damage to the mucous membranes.

Choice C is wrong because an irrigation set is not needed for a tracheostomy tube.

Irrigation can introduce bacteria and increase the risk of infection. It can also cause coughing and bleeding.

Choice D is wrong because hemostats are not used for a tracheostomy tube.

Hemostats are surgical instruments that are used to clamp blood vessels or tissues. They have no role in tracheostomy care.

Some other supplies that the nurse should place in the room are a trach tube the same size as the current tube and one size smaller, a portable suction machine with battery backup, and tubing that connects to the suction machine. Other supplies may include saline solution, syringes, gauze squares, gloves, a trachea tube brush, a waterproof drape, non-woven sponges, pipe cleaners, cotton tipped applicators, a T-drain sponge, twill tape, a trach holder, a speaking valve, a stoma cover, and a nebulizer.