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

Answer and Explanation

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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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.

A. Capillary refill and depth of peripheral edema B. Abdominal sounds and obtain a BNP level C. Neurological status and obtain electrolyte levels D. Skin turgor and measure intake & output (I&O)

Correct Answer is C

Explanation

A. Capillary refill and depth of peripheral edema: While these assessments are important for evaluating peripheral circulation and fluid status, they are not as immediately critical given the client's new onset of confusion and respiratory symptoms.
B. Abdominal sounds and obtain a BNP level: Assessing abdominal sounds and BNP (B-type natriuretic peptide) levels is useful for diagnosing heart failure exacerbations but is secondary to addressing the client's acute confusion and potential electrolyte imbalances.
C. Neurological status and obtain electrolyte levels: This is the correct choice. New onset confusion can be indicative of electrolyte imbalances or acute exacerbations related to heart failure. Monitoring neurological status and electrolyte levels is crucial to address potential causes of confusion and ensure proper treatment.
D. Skin turgor and measure intake & output (I&O): While skin turgor and I&O are relevant for assessing fluid status, the priority should be addressing the acute change in mental status and potential underlying causes such as electrolyte imbalances.

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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)

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Naxlex Comprehensive Predictor Exams

A client with acute pain is prescribed a sustained-release opioid that is administered every 12 hours. After 6 hours, the client complains of increasing pain that is rated as 9/10. Which intervention by the nurse is most appropriate to address the client's pain?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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