A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?

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

While advanced practice nurses like nurse practitioners can diagnose and treat, the statement implies that all experienced nurses have this independent authority. In many settings, the registered nurse functions within a collaborative scope and follows established protocols or physician orders. Claiming independent medical ordering for all nurses is inaccurate and misrepresents the legal scope of practice. The role of the nurse is distinct from the medical model, focusing more on holistic care and patient advocacy.

Choice B rationale

Making a medical diagnosis is specifically the legal responsibility of a physician or a licensed healthcare provider with prescriptive authority. While nurses are indeed at the bedside and identify physiological changes, they provide a nursing diagnosis rather than a medical one. Nurses observe symptoms and report findings to the medical team for formal diagnosis. Confusing these roles can lead to legal complications and a misunderstanding of professional boundaries. The nurse's expertise lies in monitoring and managing the patient's health status.

Choice C rationale

Stating that nurses do everything is an overgeneralization that fails to define the unique and specialized scope of the profession. While nurses are versatile and work across various departments, their work is guided by specific standards of practice and ethical codes. This description lacks the scientific and professional rigor that characterizes modern nursing. It ignores the collaborative nature of healthcare where different disciplines contribute specific expertise. Nursing is a distinct science centered on the patient's response to their health condition.

Choice D rationale

This statement accurately reflects the definition of nursing as a profession. Nurses focus on the human response to actual or potential health problems, encompassing physical, emotional, and social aspects. This includes managing symptoms, providing comfort, and promoting health through education and intervention. It distinguishes nursing from medicine by highlighting the holistic approach to how a patient experiences and copes with illness. This role is essential for ensuring patient safety and improving quality of life during and after medical treatment.