A nurse is discussing the process of evidence-based practice (EBP). Which of the following sources should the nurse identify as being examples of credible sources of information? (Select All that Apply.)

Explanation:

A. Moist mucous membranes - This is unlikely in an end-of-life scenario. As death approaches, mucous membranes often become dry due to decreased fluid intake and decreased body function.

B. Tachycardia - Tachycardia, or a rapid heart rate, can be a common finding as death nears. It can result from various factors such as dehydration, fever, pain, or the body's response to stress.

C. Irregular respirations - Irregular respirations, including periods of apnea or agonal breathing (gasping, irregular, or shallow breaths), are typical findings in the end-of-life stage. These irregularities are part of the body's natural process as it shuts down.

D. Hypertension - Hypertension is less common in the end-of-life phase. Typically, blood pressure decreases as the body's systems begin to fail.

Explanation:

A. Right communication:

This refers to providing clear and concise instructions to the assistive personnel regarding the delegated task. Effective communication ensures that the AP understands the task, its objectives, any limitations or special considerations, and the expectations regarding its completion. Clear communication helps prevent misunderstandings and promotes safe and efficient task execution.

B. Right room:

This choice does not directly relate to the five rights of delegation. The "right room" concept may refer to ensuring that the environment or room where care is provided is appropriate, safe, and conducive to the task being performed. While environmental factors are important in healthcare, they are not part of the specific rights of delegation.

C. Right time:

The "right time" aspect of delegation involves considering the timing of the task within the overall care plan. It includes assessing whether the task should be performed immediately, at a specific time, or within a particular timeframe. Delegating tasks at the right time ensures that they align with the client's needs and the overall care schedule.

D. Right documentation:

This refers to documenting the delegation process, including details such as the delegated task, the personnel involved, any specific instructions or limitations provided, and the outcomes or results of the task. Documentation is crucial for accountability, continuity of care, and legal purposes, ensuring that there is a record of who performed the task and how it was carried out.