The charge nurse observes a new nurse during the administration of two different liquid medications at once through a gastrostomy tube used for enteral feeding. The charge nurse observes the new nurse's actions, as seen in the video.

What action(s) should the charge nurse take? (Select all that apply.)

Choice A reason: This is a correct answer because obtaining postoperative vital signs for a client one day following unilateral knee arthroplasty is a nursing action that can be assigned to the PN. Vital signs are measurements of the body's basic functions, such as temperature, pulse, blood pressure, and respiration. Vital signs should be monitored regularly after surgery to detect any signs of infection, bleeding, shock, or pain. The PN has the knowledge and skill to measure and record vital signs and report any abnormal findings to the nurse.

Choice B reason: This is a correct answer because performing daily surgical dressing change for a client who had an abdominal hysterectomy is a nursing action that can be assigned to the PN. Surgical dressing is a material that covers and protects a wound from infection, bleeding, or contamination. Surgical dressing should be changed daily or as needed to keep the wound clean and dry and promote healing. The PN has the knowledge and skill to perform surgical dressing change using sterile technique and appropriate equipment and report any signs of wound infection or dehiscence to the nurse.

Choice C reason: Initiating patient controlled analgesia (PCA) pumps for two clients immediately postoperatively is not a nursing action that can be assigned to the PN. PCA pump is a device that allows the client to self-administer pain medication through an IV line by pressing a button. PCA pump should be initiated by the nurse after verifying the prescription, setting the parameters, educating the client, and ensuring safety and effectiveness. The PN does not have the authority or competency to initiate PCA pump or adjust its settings.

Choice D reason: Starting the second blood transfusion for a client twelve hours following a below knee amputation is not a nursing action that can be assigned to the PN. Blood transfusion is a procedure that delivers donated blood or blood products into the client's bloodstream through an IV line. Blood transfusion should be started by the nurse after verifying the prescription, checking the blood type and compatibility, obtaining informed consent, and monitoring for any adverse reactions. The PN does not have the authority or competency to start blood transfusion or manage its complications.

Choice E reason: This is a correct answer because monitoring a dose of warfarin per protocol for a client with type 2 diabetes mellitus (DM) is a nursing action that can be assigned to the PN. Warfarin is an anticoagulant medication that prevents blood clots by inhibiting vitamin K dependent clotting factors. Warfarin should be monitored per protocol by checking the international normalized ratio (INR), which measures how long it takes for blood to clot. The PN has the knowledge and skill to monitor warfarin per protocol by obtaining blood samples, performing point-of-care testing, and reporting results to the nurse.

Choice B reason: the client with antisocial behavior is at risk of being harmed by other clients or harming others. The nurse should intervene immediately to prevent violence and ensure safety.

Choice A reason: the client with anorexia nervosa who is refusing to eat the evening snack is not in immediate danger. The nurse should monitor the client's nutritional status and weight, but this can be done later.

Choice C reason: the client with bipolar disorder who is pacing around the lobby is not in immediate danger. The nurse should assess the client's mood and energy level, but this can be done later.

Choice D reason: the client with major depression who refuses to participate in group is not in immediate danger. The nurse should encourage the client to join the group, but this can be done later.