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 C

Explanation

A. A 58-year-old client who uses antacids every day: Antacids primarily affect gastric acid levels and are not typically associated with respiratory acidosis. They might affect metabolic balance but not respiratory acidosis.
B. A 48-year-old client with an anxiety disorder: Anxiety disorders are more commonly associated with respiratory alkalosis due to hyperventilation, not respiratory acidosis.
C. A 68-year-old client with chronic lung disease: This is the correct choice because chronic lung diseases, such as chronic obstructive pulmonary disease (COPD), often impair CO2 elimination, leading to respiratory acidosis due to CO2 retention.
D. A 28-year-old client with salicylate intoxication: Salicylate intoxication is often associated with metabolic acidosis, and initially, it can cause respiratory alkalosis due to hyperventilation, rather than respiratory acidosis.

A. Hypocalcemia B. Hypokalemia C. Hypophosphatemia D. Hyponatremia

Correct Answer is A

Explanation

A. Hypocalcemia: Hypocalcemia can cause signs such as muscle twitching, spasms, or tetany, which could be observed in the upper extremity and might be noted during a blood pressure measurement.
B. Hypokalemia: While hypokalemia can cause muscle weakness and cramping, it is less directly associated with specific upper extremity signs compared to hypocalcemia.
C. Hypophosphatemia: This generally affects energy levels and muscle function but is less commonly associated with immediate and visible upper extremity signs.
D. Hyponatremia: This primarily affects fluid balance and mental status, and is less likely to present with specific upper extremity findings during a blood pressure check.

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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)

Nursing Test Bank

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