A nurse wants to prepare a patient report utilizing SBAR, which she knows is a systematic method of communication. To ensure the report is thorough, what types of information does she need? SELECT ALL THAT APPLY:

Assistive personnel (AP), also known as unlicensed assistive personnel (UAP), can perform tasks such as recording vital signs ¹. Collecting intake and output [a] is a task that can be delegated to an AP.

The other options are not tasks that should be delegated to an AP.

Evaluating pain relief after administering pain medication [b] involves assessing the effectiveness of a medical intervention, which is typically the responsibility of a licensed nurse.

Providing a central line dressing change [c] is a complex task that requires specialized knowledge and skills.

Selecting a menu for a low-sodium diet [d] involves dietary planning, which is typically the responsibility of a licensed nurse or a registered dietitian.

The correct answer is Choice C.

Choice A rationale: Obtaining consent directly from a client who has received IV morphine sulfate is invalid due to impaired cognitive function. Morphine acts on mu-opioid receptors in the central nervous system, reducing alertness, memory retention, and decision-making capacity. Informed consent requires full comprehension of risks, benefits, and alternatives. Morphine’s sedative effects compromise this standard. Normal Glasgow Coma Scale should be 15 for full alertness; sedation lowers this, rendering consent legally and ethically unsound.

Choice B rationale: The nurse cannot legally sign the consent on behalf of the client, even if the client is acknowledged. This violates the principle of autonomy and informed decision-making. The nurse’s role is to witness the client’s signature, not substitute it. Morphine impairs cognition, and any consent obtained under its influence is invalid. Legal standards require that the client be alert, oriented, and capable of understanding the procedure. Proxy consent must be pursued if capacity is compromised.

Choice C rationale: When a client is under the influence of opioids and lacks decision-making capacity, consent must be obtained from a legally authorized representative, such as a relative or healthcare proxy. Morphine alters consciousness and impairs executive function, making the client temporarily incompetent. Legal surrogates are empowered to make healthcare decisions in such cases. This ensures ethical compliance and protects patient rights. The nurse must verify documentation of proxy authority before proceeding with consent.

Choice D rationale: Delaying the procedure may be necessary if no authorized proxy is available, but it is not the first action. The priority is to identify and contact a legally authorized representative to obtain valid consent. Delays can compromise care, especially in urgent surgical cases. The nurse must act promptly to secure proxy consent, ensuring procedural integrity and patient safety. Only if no proxy is reachable should delay be considered, with documentation of rationale.