A nurse is using an IV pump for a newly admitted client. Which of the following actions should the nurse take?

A. Irrigate a client's incision: Wound irrigation is a sterile procedure that requires nursing judgment and skill to prevent infection and assess wound healing. This task should not be delegated to assistive personnel.

B. Determine a client's pain level: Assessing pain requires clinical judgment to interpret subjective and objective findings and evaluate the need for interventions. This responsibility remains with the licensed nurse.

C. Insert a nasogastric tube: Insertion of a nasogastric tube is an invasive procedure that requires nursing knowledge and technical skill to ensure proper placement and prevent complications. It is not within the scope of assistive personnel.

D. Provide postmortem care: Postmortem care is a noninvasive task that involves preparing the body, performing hygiene, and maintaining dignity. It falls within the scope of practice for assistive personnel and can be safely delegated.

Rationale:

A. "I don't think you understand the risks to your health.": This response is dismissive of the client’s autonomy and implies the nurse is questioning the client’s decision-making ability. It can create a defensive reaction rather than supporting informed consent.

B. "You should talk with your family about it first.": While family support can be helpful, the decision for surgery ultimately rests with the client. Suggesting family involvement at this point could undermine the client’s right to make an independent healthcare decision.

C. "I will notify your provider regarding this decision.": This response respects the client’s autonomy and ensures the healthcare team is promptly informed. It also facilitates further discussion between the provider and client about the decision, ensuring it is fully informed.

D. "Let me remind you of the benefits of the surgery.": While reviewing benefits can be part of informed consent, doing so after the client has expressed a clear decision not to proceed may be perceived as coercive rather than supportive.