A nurse working at an assisted living facility is helping emergency medical services (EMS) triage clients after a fire in the building. The 83-year-old client suffered smoke inhalation. The client is coughing with a respiratory rate of 36 and reports shortness of breath. Using the START triage, what acuity level should be assigned to this client?

Choice A reason: An incident report is necessary when a client discovers that his dentures are missing. This situation involves a loss of personal property and could potentially lead to further complications, such as the client being unable to eat properly or experiencing distress. Documenting the incident ensures proper follow-up and resolution.

Choice B reason: While identifying a broken piece of equipment is important and should be addressed, it does not typically require an incident report unless the equipment failure has directly caused harm or posed a significant risk to a client or staff member. Reporting the issue through maintenance channels is usually sufficient.

Choice C reason: A disagreement between the nurse and the nursing supervisor about staffing is an internal issue that should be addressed through appropriate channels such as team meetings or discussions with management, rather than an incident report.

Choice D reason: A staff member not showing up for their assigned shift is a staffing issue that should be managed through scheduling and human resources processes. It does not typically warrant an incident report unless it directly leads to an adverse event affecting client care.

Choice A reason: Documenting the client's fingerstick blood glucose is a task that can be safely delegated to the UAP. This task involves recording a numeric value from a glucometer reading, which does not require clinical judgment or decision-making. UAPs are trained to perform and document such routine measurements accurately.

Choice B reason: Monitoring vital signs during a blood transfusion should not be delegated to a UAP. This task requires clinical judgment to identify and respond to potential adverse reactions, such as transfusion reactions, which is within the scope of practice for licensed nurses, not UAPs.

Choice C reason: Examining output from a client's surgically placed drain involves assessing the amount, color, and type of drainage, which requires clinical judgment to determine the significance of the findings. This task should be performed by a licensed nurse who can evaluate the client's condition and respond appropriately.

Choice D reason: Obtaining central venous pressure (CVP) measurements is a complex procedure that requires specialized knowledge and skills. It involves understanding hemodynamic monitoring and interpreting the measurements, which falls within the scope of practice for licensed nurses, not UAPs.