An assistive personnel (AP) comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which of the following statements by the nurse is appropriate?

Rationale:

A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 needs pain management, but this is less urgent compared to potential signs of hypotension.

B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous indicates normal progression of wound healing; thus, it is less critical.

C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL needs blood glucose management, but this is less urgent than assessing for potential hypovolemia or shock.

D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg is experiencing a significant drop in blood pressure, which could indicate hypovolemia or shock. This requires immediate assessment and intervention to prevent complications.

Rationale:

A. Protective isolation could be managed by any qualified RN, LPN, or AP depending on the complexity.

B. A client actively dying and requiring IV pain medication needs specialized assessment and pain management, which is appropriate for an RN.

C. A client 3 days postoperative requires ongoing care that can be managed by an LPN with supervision.

D. Frequent ambulation is a task that can be managed by an AP, though supervision may be needed.