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.
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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Related Questions
Correct Answer is D
Explanation
The client is pacing around the chair in which their partner is sitting.
Rationale:
- A. The client is taking numerous deep, measured breaths. This is not an indication of potential violence, but rather a coping strategy to calm down and regulate emotions.
- B. The client is calmly telling their partner that "the staff here is so controlling." This is not an indication of potential violence, but rather a expression of frustration or dissatisfaction with the treatment setting.
- C. The client is sitting with their head in their hands and appears to be crying. This is not an indication of potential violence, but rather a sign of sadness or distress.
- D. The client is pacing around the chair in which their partner is sitting. This is an indication of potential violence, as it shows restlessness, agitation, and possible intimidation of the partner.
Correct Answer is B
Explanation
Choice A rationale:
Documenting the client's vital signs obtained by an assistive personnel is incorrect. Vital signs are essential clinical measurements that should be taken by qualified healthcare professionals, such as nurses. Allowing assistive personnel to obtain vital signs without supervision could compromise the accuracy of the data, potentially leading to incorrect assessments and decisions about the client's condition.
Choice B rationale:
Charting a summary of the data at the change of the shift is incorrect. While it's essential to provide an update at shift change, this option suggests summarizing the data, which might not include all necessary details. Comprehensive documentation is crucial for continuity of care and accurate communication among healthcare providers. Documenting specific vital signs, assessments, interventions, and the client's response to those interventions is necessary for effective patient care.
Choice C rationale:
Noting whether the client has a living will is incorrect. While it's essential to be aware of a client's advanced directives, this information is typically gathered during the admission process or during routine assessments. It is not the immediate action to be taken upon admission. Vital signs and other immediate clinical data take precedence during the initial documentation process.
Choice D rationale:
Beginning charting with an evaluation of the data is incorrect. It is important to document objective data, such as vital signs, observations, and assessments, before making any evaluations or interpretations. Objective data provide the basis for clinical decisions and interventions. Starting with evaluations might lead to biased documentation, potentially overlooking important clinical findings.
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