A nurse is planning care for a client who has Addison's disease. Which of the following tasks should the nurse plan to delegate to an assistive personnel?
Explain to the client about a 24-hr urine specimen collection.
Remind the client to change positions slowly.
Determine the client's muscle strength prior to ambulation.
Decide how often to measure vital signs.
The Correct Answer is B
Rationale:
A. Explaining a 24-hr urine specimen collection requires teaching, which is a nursing responsibility and cannot be delegated to assistive personnel (AP).
B. Reminding the client to change positions slowly is reinforcement of prior teaching and is appropriate to delegate to an AP.
C. Determining muscle strength requires assessment, which is the nurse’s responsibility and cannot be delegated.
D. Deciding how often to measure vital signs involves nursing judgment and care planning, which cannot be delegated to an AP.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A. It is not appropriate for the client to independently mark the operative site; this could lead to errors. Site marking must be done by the surgical team per protocol.
B. Contacting the surgery department does not directly resolve the client’s confusion or ensure proper informed consent.
C. The surgeon is responsible for confirming and clarifying the surgical site with the client. The nurse should advocate for the client’s safety by notifying the surgeon of the discrepancy.
D. Proceeding with surgery despite the client’s expressed concern would be unsafe and violates the principles of informed consent and patient safety.
Correct Answer is ["A","B","E","F","H","I"]
Explanation
Rationale:
A. Hydration status: Nausea, vomiting, and limited oral intake put the client at risk for dehydration, requiring monitoring and possible intervention.
B. Heart rate: Increased from 80/min at 1730 to 102/min at 2300, indicating possible systemic stress or dehydration.
E. Headache: Client reports a severe headache (7/10), which can indicate systemic worsening or complications.
F. Temperature: Rose to 39° C (102.2° F), showing worsening infection.
H. Emesis: Client vomited 230 mL, which can contribute to fluid and electrolyte imbalance.
I. Blood pressure: Increased from 118/72 mm Hg to 152/92 mm Hg, suggesting possible stress response, pain, or early complications.
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