A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Palpate the degree of edema.

Regulate IV pump fluid rate.

Measure the client's daily weight.

Assess the client's vital signs.

Answer and Explanation

The Correct Answer is C

A. Palpate the degree of edema. This is incorrect because palpating the degree of edema requires clinical judgment and skill, which are beyond the scope of practice of an AP.

B. Regulate IV pump fluid rate. This is incorrect because regulating IV pump fluid rate is a nursing responsibility that involves calculating and adjusting the infusion rate based on the client's condition and orders.

C. Measure the client's daily weight. This is correct because measuring the client's daily weight is a routine task that can be delegated to an AP, as long as the nurse provides clear instructions and monitors the results. The client's daily weight is an indicator of fluid balance and can help evaluate the effectiveness of treatment.

D. Assess the client's vital signs. This is incorrect because assessing the client's vital signs requires interpretation and analysis of data, which are nursing functions that cannot be delegated to an AP.

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Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

Completed Sentence: The client is at risk for developing hemorrhagic stroke due to autonomic dysreflexia. Rationale: Hemorrhagic Stroke: This is a serious condition that can occur as a complication of a high spinal cord injury. Due to the injury at T4, the client may be at risk for blood pressure dysregulation, which can lead to a hemorrhagic stroke. Autonomic Dysreflexia: This condition is characterized by a sudden increase in blood pressure, often triggered by stimuli such as a full bladder, bowel distention, or pain. In this client, the headache rated 9/10, diaphoresis, flushed skin, agitation, labored breathing, and elevated blood pressure (185/105 mm Hg) are indicative of autonomic dysreflexia.

A. Administer the medication and alert the charge nurse. B. Hold the medication and document cardiac assessment. C. Administer the medication and document the heart rate. D. Hold the medication and recheck the heart rate in 1 hour.

Correct Answer is C

Explanation

a. Administer the medication and alert the charge nurse: This choice suggests proceeding with medication administration but also informing the charge nurse. While it's important to communicate with the charge nurse regarding medication administration, in this scenario, there is no indication to hold the medication as the infant's heart rate is within the normal range. Therefore, alerting the charge nurse may not be necessary at this point.

b. Hold the medication and document cardiac assessment: This choice suggests holding the medication and documenting the cardiac assessment. However, since the infant's heart rate is within the normal range for their age, there is no clinical indication to hold the medication. Holding the medication unnecessarily could delay treatment and potentially lead to adverse outcomes if the medication is needed.

c. Administer the medication and document the heart rate.

Since the infant's heart rate of 120 beats per minute falls within the normal range for a 2-month-old, there is no indication to hold the medication. Administering the digoxin as prescribed and documenting the heart rate before administration are appropriate actions. It's important to ensure accurate documentation to track the infant's response to the medication and monitor for any changes in heart rate.

d. Hold the medication and recheck the heart rate in 1 hour: This choice suggests holding the medication and rechecking the heart rate in 1 hour. Again, since the infant's heart rate is within the normal range, there is no clinical indication to hold the medication or delay treatment. Rechecking the heart rate in 1 hour would be unnecessary and could potentially delay necessary medication administration.

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A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury. Exhibits Select 1 condition and 1 client finding to fill in each blank in the following sentence.</p> The client is at risk for developing dropdown due to dropdown .

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?

Correct Answer is C

Explanation

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