The practical nurse (PN) enters the room of a client who underwent a mastectomy eight hours ago. The PN observes the unlicensed assistive personnel (UAP) preparing to measure the client's blood pressure using an automated blood pressure device on the client's operative side. Which action should the PN implement?

A. Notifying the charge nurse is important but should come after confirming the accurate heart rate assessment.
B. Holding a prescribed morning dose of digoxin may be necessary if bradycardia is confirmed, but the first step is to accurately assess the heart rate.
C. Obtaining a full minute apical pulse assessment is the first step to verify the radial pulse rate reported by the UAP and ensure an accurate and comprehensive assessment of the client's heart rate.
D. Reviewing the client's baseline vital signs is useful but should follow a thorough and accurate assessment of the current heart rate.

A. Acetaminophen 600 mg PO every 6 hours PRN for pain or temperature greater than 100° F (37.7° C)
While acetaminophen is necessary for managing fever or pain, it is a PRN medication, meaning it is only given based on specific symptoms (temperature greater than 100°F or pain). Immediate administration is not required unless the client’s symptoms meet these criteria.
B. Contact precautions
Contact precautions are crucial for preventing the spread of MRSA, a highly contagious pathogen. Immediate implementation is necessary to protect both the client and others in the healthcare setting from infection.
C. Vancomycin 500 mg IV piggyback every 6 hours
Vancomycin is prescribed to treat the MRSA infection. It should be administered as ordered to manage the infection effectively and prevent complications from the surgical site infection.
D. Place peripheral IV
The peripheral IV has already been placed, as indicated by the notes. This action would have been necessary before starting the IV medication orders but is not an immediate task at this time.
E. Change turban dressing by cleansing with sterile water, patting dry, applying dry gauze over incision, and wrapping head with kerlix
Changing the turban dressing is necessary to manage the infection at the surgical site. This must be done according to the prescribed procedure to maintain sterile conditions and support healing.
F. Strict intake and output
While monitoring intake and output is important, it does not need to be done immediately but should be started as per the order to monitor the client’s fluid balance over time.
G. Clear liquid diet
Initiating a clear liquid diet is important for nutritional support, but it does not need to be started immediately. It is part of the general care plan but does not have the same urgency as infection control and medication administration