The nurse walks into the client’s room and notices fire coming from the trash can. Place the following actions in the order the nurse should perform them:

1. Close all of the doors and windows
2. Activate the fire alarm
3. Extinguish the fire using the proper fire extinguisher
4. Move the client from the room

Choice A reason: A Kayexalate enema for severe hypokalemia should be questioned, as Kayexalate removes potassium to treat hyperkalemia, not hypokalemia. Administering it for low potassium would worsen the condition, risking arrhythmias, making this an incorrect and dangerous order.

Choice B reason: A hypertonic solution enema for fluid volume excess is appropriate, as it draws fluid into the bowel, aiding evacuation and reducing systemic fluid overload. This aligns with the patient’s condition, making it a correct order that does not require questioning.

Choice C reason: A normal saline enema repeated until stool is produced is safe, as saline is isotonic and effective for constipation relief without causing fluid or electrolyte imbalances. This is a standard order, making it appropriate and not requiring no questioning.

Choice D reason: An oil retention enema for constipation is appropriate, as it lubricates stool, facilitating evacuation. This is a standard treatment for relieving constipation, aligning with the patient’s needs, making it a correct order that does not require questioning.

Choice A reason: Irrigating an NG tube involves assessing patency and suction, which requires clinical judgment beyond UAP scope. This task involves potential complications (e.g., aspiration), making it inappropriate for delegation to unlicensed personnel.

Choice B reason: Performing digital removal of stool is a skilled procedure with risks (e.g., vagal stimulation, bleeding), requiring RN expertise. It is outside the UAP scope, as it involves invasive intervention and assessment, making it inappropriate for delegation.

Choice C reason: Measuring stool in a colostomy bag is a routine, non-invasive task within UAP scope, involving observation and reporting output. It requires no clinical judgment or sterile technique, making it the most appropriate task for delegation to unlicensed personnel.

Choice D reason: Changing a central line dressing requires sterile technique and assessment for infection, which are RN responsibilities. UAPs lack training for sterile procedures and complex site evaluation, making this task inappropriate for delegation.