A client with a diagnosis of colorectal cancer has been presented with her treatment options, but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture.
The client's right to self-determination is best protected by

Choice A rationale

The nurse practice act and agency policy provide the legal and organizational framework for nursing practice and delegation. Determining if the delegation of topical medication administration is permissible under these guidelines is the foundational first step to ensure legality and adherence to established protocols.

Choice B rationale

Assessing the UAP's training is crucial for safe delegation, but it's secondary to ensuring that the task is delegable in the first place according to legal and policy guidelines. Training is irrelevant if the task cannot be delegated.

Choice C rationale

Ensuring appropriate supervision is essential for delegated tasks, but again, it's contingent on whether the task can be legally and organizationally delegated. Supervision protocols come into play after the initial permissibility of delegation is established.

Choice D rationale

Evaluating the client's past response to the treatment is important for ongoing care but doesn't determine the initial delegability of the task to a UAP. The focus of the first question is on the legal and policy aspects of delegation. .

Choice A rationale

Fluid Volume Excess occurs in congestive heart failure due to the heart's inability to pump blood effectively, leading to increased hydrostatic pressure in the capillaries. This pressure forces fluid into the interstitial spaces, causing edema. Orthopnea, or difficulty breathing while lying flat, results from the redistribution of this excess fluid into the pulmonary circulation when supine, increasing pressure in the lungs.

Choice B rationale

Fluid Volume Deficit is characterized by dehydration, typically presenting with symptoms like poor skin turgor, dry mucous membranes, and concentrated urine. Confusion in dehydration is due to reduced cerebral perfusion. These signs and symptoms are contrary to the findings of edema and orthopnea, which indicate fluid overload, not deficit.

Choice C rationale

Impaired Gas Exchange is a potential complication of congestive heart failure due to fluid accumulation in the lungs (pulmonary edema). While orthopnea is a symptom of this, the primary evidence for impaired gas exchange would be abnormal blood gas values (e.g., low PaO2, high PaCO2) and clinical signs of hypoxemia, not just orthopnea and shortness of breath alone.

Choice D rationale

Risk for Falls is a relevant concern for an elderly client with confusion, as altered mental status can impair judgment and coordination, increasing the likelihood of falls. However, this diagnosis does not directly address the primary physiological problem of fluid overload evidenced by edema and orthopnea in the context of heart failure.