Exhibits

A nurse is collecting data from a 6-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data)

A. Performing a gastrostomy feeding on a stable client: Gastrostomy tube feedings involve sterile technique, monitoring for complications, and assessment of tolerance. These tasks require RN judgment and should not be delegated to assistive personnel.

B. Changing a sterile dressing for a client who is postoperative: Sterile dressing changes involve maintaining asepsis and assessing the wound for signs of infection or complications. This requires professional nursing skill and cannot be safely delegated to assistive personnel.

C. Providing postmortem care to a client: Postmortem care is a noninvasive, routine task that does not require nursing judgment. It can safely be delegated to assistive personnel while ensuring dignity and proper procedure are maintained.

D. Observing the patency of an intravenous catheter on a stable client: Monitoring IV patency requires assessment skills to detect infiltration, phlebitis, or other complications. This task should remain the responsibility of a licensed nurse.

A. Observe the client during and after meals: Monitoring the client for bingeing or purging behaviors is the priority intervention because it addresses immediate safety and physical health risks, such as electrolyte imbalances. Direct observation prevents harmful behaviors and allows timely intervention.

B. Refer the client to a support group for clients who have eating disorders: Referral is important for long-term psychosocial support, but it does not address immediate risk or safety concerns during meals.

C. Instruct the client about effective coping strategies: Teaching coping strategies is beneficial for long-term management, but ensuring safety during meals takes precedence in the nursing process.

D. Suggest that the client assist with meal planning: Involving the client in meal planning promotes autonomy and engagement in treatment, but it is not the first action when immediate monitoring is required to prevent harmful behaviors.