The practical nurse (PN) is assessing a client's blood pressure using a manual sphygmomanometer on the left arm. In which sequence should the PN implement these actions? (Arrange from first action on top to last on the bottom.)

A. Confirm that the medication is only administered once daily: The frequency of administration is verified when reviewing the prescription, not during the administration process. This step does not address the observed technique or ensure safe practice.

B. Determine if the medication is compatible with the solution: Checking compatibility is important before mixing medications with enteral feedings, but the question focuses on the PN’s observation of an improper administration technique, requiring immediate intervention.

C. Offer to assist in calculating the rate of flow for the mixture: Liquid medications given via feeding tubes are not typically infused at a specific rate but administered separately from feedings to prevent interaction or tube blockage, so rate calculation is unnecessary.

D. Demonstrate how to administer medication via a feeding tube: The appropriate response is to stop the incorrect procedure and demonstrate proper technique. Medications should be given separately from feedings, flushed with water before and after, and never mixed directly into the feeding solution.

A. The PN will place a gait belt on the client prior to ambulation: Using a gait belt is a nursing intervention that enhances safety during ambulation, but it is not an outcome statement. Desired outcomes should describe the client’s behavior or achievement rather than the nurse’s actions.

B. The client will use self-affirmation statements to decrease fear: Positive self-talk may help reduce anxiety, but it does not address the measurable improvement in physical mobility. The goal should reflect functional progress in ambulation, which indicates recovery and confidence.

C. The physical therapist will instruct the client in the use of a walker: This describes an interdisciplinary intervention rather than a client-centered outcome. While physical therapy support is important, the desired outcome should focus on what the client is expected to accomplish.

D. The client will ambulate with assistance q4 hours: This outcome is specific, measurable, and directly related to the diagnosis of impaired mobility. It demonstrates progress toward overcoming the fear of falling through supported activity and aligns with nursing goals to restore safe mobility.