A nurse asks the unlicensed assistive personnel (UAP) to assist in determining the fluid status of a client. Which of the following actions should the nurse delegate to the UAP? (Select All That Apply)
Record intake and output
Assess bowel sounds
Obtain routine vital signs
Document the presence of edema
Correct Answer : A,C,D
A. Record intake and output: This task is within the UAP's scope of practice as it involves documenting fluid balance.
B. Assess bowel sounds: This task requires clinical judgment and assessment skills and should be performed by a licensed nurse.
C. Obtain routine vital signs: This is appropriate for the UAP to perform, as it involves routine measurements that do not require clinical assessment.
D. Document the presence of edema: The UAP can document observable findings such as edema, which is within their scope of practice.
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Related Questions
Correct Answer is B
Explanation
A. Teach the client a relaxation technique to use until the next dose is due: While relaxation techniques can be helpful in managing pain, they are not sufficient for severe pain rated 9/10. The client requires more immediate pharmacological intervention.
B. Obtain an order for an immediate-release opioid for breakthrough pain: This is the most appropriate action. Immediate-release opioids are specifically used to manage breakthrough pain in clients on sustained-release opioid therapy. It addresses the client's severe pain effectively and promptly.
C. Explain to the client that the medication being administered lasts for 12 hours: Simply explaining the duration of the medication does not address the client's current severe pain. Effective pain management requires action, not just education.
D. Assess the client's vital signs and administer the next dose of opioids early: Administering the next dose early can lead to inappropriate dosing schedules and potential overdose. It is important to follow the prescribed dosing regimen and manage breakthrough pain appropriately.
Correct Answer is D
Explanation
A. Dry oral mucus membranes: This finding indicates dehydration rather than improvement. Effective treatment would result in the rehydration of mucous membranes.
B. Weight loss: Weight loss can be a sign of ongoing dehydration or fluid loss. Effective treatment would be indicated by weight stabilization or gain, not loss.
C. Jugular vein distention: Jugular vein distention typically indicates fluid overload or poor cardiac function, not improvement in dehydration. Effective rehydration would be associated with a return to normal vein appearance.
D. Daily urine output of 960 mL: This is the correct choice as it reflects adequate fluid intake and kidney function. For an average adult, a daily urine output of around 960 mL suggests proper hydration, indicating that interventions have been effective.
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