After the change-of-shift report, the practical nurse (PN) makes rounds on a postoperative unit. Which client finding necessitates the Immediate attention of the PN?

A. This is a client care intervention that the PN can assign to the UAP. Transporting a urine culture sample to the laboratory is a routine and non-invasive task that does not require clinical judgment or skill. The UAP should follow the standard precautions and protocols for handling and labeling the specimen.

E. This is a client care intervention that the PN can assign to the UAP. Emptying the bedside drainage unit for a client with an indwelling urinary catheter is a routine and non-invasive task that does not require clinical judgment or skill. The UAP should follow the standard precautions and protocols for emptying, measuring, and recording the urine output.

B. This is not a client care intervention that the PN can assign to the UAP. Obtaining a post-voided residual (PVR) volume is a procedure that requires clinical judgment and skill, as it involves using a bladder scanner or catheterizing the client to measure the amount of urine left in the bladder after voiding. The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.

C.This is not a client care intervention that the PN can assign to the UAP. Teaching the client with fluid restrictions how to measure urine output is an educational activity that requires clinical judgment and skill, as it involves assessing the client's learning needs, providing clear and accurate instructions, and evaluating the client's understanding and compliance. The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.

D.This is not a client care intervention that the PN can assign to the UAP. Irrigating an indwelling urinary catheter for a client with bladder suspension is a procedure that requires clinical judgment and skill, as it involves inserting sterile fluid into the bladder through the catheter to flush out any clots, debris, or bacteria. The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.

The client is prescribed oxygen at 3 liters per minute, but the flowmeter shows that only 1 liter of oxygen is being delivered. This indicates an inadequate oxygen supply and immediate action is required to adjust the flow rate to meet the prescribed oxygen requirement. Failure to provide the appropriate oxygen flow rate can compromise the client's respiratory status and oxygenation. The PN should promptly increase the flow rate to the prescribed level to ensure the client receives the necessary oxygen therapy.
The other assessment findings mentioned are also important to note and address, but they do not require immediate action:
A. The client lying in a supine position in bed: While it is generally recommended for clients receiving oxygen therapy to be in an upright or semi-upright position, this finding does not require immediate action unless there are specific indications or contraindications related to the client's condition.
B. The cannula pressed snugly against the client's cheeks: The cannula should fit comfortably and securely on the client's face without causing discomfort or pressure areas. While this finding may require adjustment to ensure proper fit and comfort, it does not require immediate action unless it is causing harm or compromising oxygen delivery.
D. There is no humidifier attached to the delivery system: While a humidifier may be recommended to add moisture to the oxygen, its absence does not pose an immediate threat to the client's safety or require immediate action. The need for humidification depends on the client's condition and comfort level, and it can be addressed by attaching a humidifier if necessary.