The nurse is caring for a patient with a history of chronic respiratory problems who has an abdominal binder in place. Which should the nurse instruct nursing assistive personnel (NAP) to report as an unexpected outcome?

Question

a. The skin around the binder is dry without redness or edema.
b. The patient experiences difficulty moving around in bed.
c. The patient's pain level has changed from 8 to 6 on a scale of 1 to 10.
d. The respiratory rate has decreased from 17 to 15 breaths per minute.

Answer 1

B
The patient's activity should not be hampered by the binder. The nurse needs to assess the pa-tient's ability to move in bed before the binder is applied and reassess after the binder has been in place for a short time. The binder may be too tight, and loosening it may be enough to allow more mobility by the patient. Assessing the skin around the binder and evaluating trends in data are nursing tasks requiring nursing assessment skills and nursing judgment and evaluation; thus the nurse avoids delegating skin assessments and data analysis. Determining the patient's pain level is a nursing function requiring assessment skills. The nurse expects the NAP to report the respiratory rate, even if normal, and the nurse draws conclusions about the data reported.