A nurse is planning to delegate a task to an assistive personnel (AP). Which of the following actions should the nurse plan to take?

A. Reassign the task to another nurse: While reassignment may be an option, it does not address the underlying issue. Ensuring the LPN has the knowledge and skill to complete the task is more effective in addressing both immediate and future concerns.

B. Report the issue to the unit manager: Reporting to the manager might be appropriate if the issue persists or reflects repeated non-compliance. However, verifying the LPN's competence and addressing the problem directly should be the first step.

C. Change the client’s dressing: While changing the dressing resolves the immediate client need, it does not address the issue of delegation or why the task was not completed. This approach bypasses the opportunity to assess and support the LPN.

D. Verify the LPN knows how to do a dressing change: Before taking further action, the charge nurse should determine why the task was not completed. If the LPN lacks the knowledge or skill to perform a dressing change, the nurse must address this gap and provide appropriate education or support to ensure client care is not compromised.

Rationale:

A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 needs pain management, but this is less urgent compared to potential signs of hypotension.

B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous indicates normal progression of wound healing; thus, it is less critical.

C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL needs blood glucose management, but this is less urgent than assessing for potential hypovolemia or shock.

D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg is experiencing a significant drop in blood pressure, which could indicate hypovolemia or shock. This requires immediate assessment and intervention to prevent complications.