A nurse is prioritizing care for four clients.
Which of the following tasks should the nurse perform first?

Choice A rationale

Postmortem care includes preparing the body for transport and respecting cultural practices, which falls within the scope of an assistive personnel’s training. It ensures dignity for the deceased and follows standard protocols, such as cleaning and positioning the body. This task does not require clinical judgment or advanced decision-making, making it suitable for delegation.

Choice B rationale

Reinforcing discharge instructions requires critical thinking and knowledge about postoperative care. This involves assessing the client’s understanding and providing tailored education, which exceeds the scope of an assistive personnel’s responsibilities. Registered nurses are more qualified for this task due to their clinical expertise.

Choice C rationale

Interpreting deviations in vital signs requires comprehensive knowledge of pathophysiology and the ability to correlate symptoms with potential medical conditions. Such tasks necessitate clinical judgment and decision-making, which are exclusive to licensed healthcare professionals, not assistive personnel.

Choice D rationale

Inserting a nasogastric (NG) tube is a technical procedure that demands sterile technique, anatomical knowledge, and the ability to recognize complications. It requires licensure and specialized training, making it unsuitable for delegation to an assistive personnel, as it could jeopardize client safety.

Choice A rationale

Documenting the doubled dose in the medical record ensures transparency and provides critical information for continuity of care. Accurate documentation allows the healthcare team to monitor the client for potential adverse effects, supporting accountability and preventing recurrence of medication errors.

Choice B rationale

Reporting the incident to the pharmacy manager addresses systemic issues, such as procedural errors or staff education needs, to prevent similar occurrences. However, this action does not directly prioritize client safety or care in response to the doubled dose.

Choice C rationale

Placing a copy of the incident report in the client’s record breaches confidentiality and violates facility policy. Incident reports are administrative tools to address safety concerns, not a part of the client’s medical record.

Choice D rationale

Contacting the nurse from the previous shift might provide insight into the error’s cause but does not address the immediate need to ensure client safety or document the error. This step is secondary to accurate record-keeping and reporting.