The practical nurse (PN) should collect the following information during the admission assessment of a terminally ill client to an acute care facility:

Bathing a bedfast client with the bed in a high position poses a potential risk to the client's safety. Lowering the bed to a safe height is important to prevent falls and injuries during the bathing procedure. The PN should promptly intervene and instruct the UAP to lower the bed to an appropriate level before continuing with the bathing process.
A. While remaining in the room to supervise the UAP is important, it should be done after ensuring the client's safety by lowering the bed. If the bed is not lowered, the risk of injury remains, and the PN should take immediate action to address the safety concern.
C. Determining if the UAP would like assistance is a valid consideration, but it should be secondary to addressing the safety issue of the bed height. Once the bed is lowered, the PN can assess if additional assistance is required and provide support accordingly.
D. Assuming care of the client immediately may be necessary if the client is in immediate danger or experiencing an urgent medical situation. However, in this case, the primary concern is addressing the safety issue related to the bed height, and the PN can address this by instructing the UAP to lower the bed.

The practical nurse (PN) who hears adventitious breath sounds while auscultating the lungs of an older adult who is receiving an IV of 5% dextrose in water (DW) at 100 mL/hour should report the findings to the charge nurse.

Adventitious breath sounds can be indicative of respiratory problems such as fluid accumulation or infection in the lungs. In this case, it is important for the PN to report the findings to the charge nurse to ensure appropriate action is taken to assess and manage the client's respiratory status.

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B- Reviewing the last balance of intake and output is important for overall assessment but may not directly address the concern of adventitious breath sounds. It can provide additional information about the client's fluid balance, but it is not the next immediate action in response to the abnormal lung sounds.

C- Slowing the DSW infusion rate to 50 mL/hour is not the most appropriate action to take based solely on the presence of adventitious breath sounds. The abnormal lung sounds may be an indication of an underlying respiratory issue that needs further evaluation and intervention.

Adjusting the infusion rate without a comprehensive assessment and appropriate medical orders could potentially overlook the underlying cause.

D- Documenting the findings and monitoring the client is necessary, but it should not be the sole action taken. Reporting the findings to the charge nurse is crucial to ensure prompt assessment and appropriate intervention.