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 D
Explanation
A. Deep breathing and coughing exercises daily: These are important for preventing respiratory complications but do not specifically address the prevention of thrombosis.
B. Removal of compression stockings at night: Compression stockings should generally be worn continuously to prevent venous stasis and thrombosis.
C. Floating the heels while lying in bed: This helps prevent pressure ulcers but is not a primary intervention for preventing thrombosis.
D. Leg exercises ten times per hour while awake: This is the correct choice. Regular leg exercises improve circulation and help prevent venous stasis, thereby reducing the risk of thrombosis.
Correct Answer is A
Explanation
A. Steak and scrambled eggs: Steak and scrambled eggs are excellent sources of heme iron, which is highly bioavailable and easily absorbed by the body. This choice reflects a good understanding of dietary sources rich in iron.
B. Cornmeal muffin and orange juice: While orange juice can enhance iron absorption due to its vitamin C content, cornmeal muffins are not a significant source of iron. This option does not indicate a strong understanding of iron-rich foods.
C. Cantaloupe and cottage cheese: Both cantaloupe and cottage cheese are low in iron content. This menu choice does not reflect an understanding of the best dietary sources of iron.
D. Strawberry pancakes and coffee: Strawberries have some iron, but not in significant amounts, and coffee can inhibit iron absorption due to its polyphenol content. This choice does not indicate an understanding of iron-rich foods.
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