Nurses should delegate tasks to unlicensed assistive personnel (UAP) to manage time effectively and ensure client needs are met. However, registered nurses (RNs) should only delegate tasks that satisfy the five rights of delegation and are within the delegatee’s scope of practice. Providing client education is out of the scope of practice for the UAP. Describing specific assessment findings for the client to report is client-teaching and requires clinical judgment. [Choice 4]. Educating a client on reportable symptoms should be performed by the RN, who has the clinical judgment and pathophysiology
knowledge to support correct teaching.

The nurse’s role in the informed consent process is to serve as a witness that the client has voluntarily provided permission for treatment. However, it’s important to note that the nurse’s role is primarily to witness the consent process, not to provide detailed education or obtain the consent itself.

Continuous cardiac monitoring is needed for clients with potassium imbalances due to the risk of lethal dysrhythmias such as complete heart block, asystole, and ventricular fibrillation. The nurse should prioritize assessing clients with possible malfunctioning equipment or abnormal monitoring results, such as a client with frequent artifacts on the telemetry monitor. Artifacts are abnormal rhythm distortions caused by movement or equipment malfunctioning. The nurse should immediately assess the client and the equipment to ensure accurate cardiac rhythm interpretation.

Clients considering suicide may provide verbal and behavioral indicators. Verbal indicators include statements suggesting hopelessness, a desire to escape, or that an ending is near (e.g., “It will all be over soon”).  Behavioral indicators include social withdrawal and putting final affairs in order. If an indicator is present, the nurse must prioritize safety by directly asking if the client is having thoughts of harming themselves. Clients may be hesitant to discuss feelings of suicide without prompting. By asking directly, the nurse indicates it is safe to talk about these feelings. Open communication allows the treatment team to provide appropriate intervention, care, and support.

During electroconvulsive therapy (ECT), an electrical current is passed through the brain, triggering a brief seizure. These seizures are thought to affect neurotransmitters (e.g., serotonin, norepinephrine, dopamine) and alleviate symptoms of severe mood disorders when less invasive approaches have been unsuccessful (e.g., medications, therapy, lifestyle modifications). Following ECT, clients experience a postictal phase, which refers to the recovery period immediately following seizure activity. During this phase, clients will likely experience confusion, disorientation, drowsiness, and temporary memory loss. Therefore, the nurse should provide frequent reorientation in the recovery phase.