Exhibits

The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply

A. Weigh every morning: Daily weighing helps monitor for fluid retention, which is important in managing heart failure. Sudden weight gain can indicate fluid accumulation and worsening heart failure symptoms, prompting the need for medical attention.
B. Limit fluid intake to 1,500 ml daily: While fluid restriction may be necessary for some
individuals with heart failure, the specific amount varies based on individual circumstances and should be determined by the healthcare provider. A blanket recommendation of 1,500 ml may not be appropriate for all patients.
C. Eat a high protein diet: While a balanced diet is important for overall health, there is no specific evidence to suggest that a high protein diet is essential for heart failure management. Dietary recommendations should be tailored to the individual's needs and comorbidities.
D. Perform range of motion exercises: While exercise is important for overall health, including for individuals with heart failure, range of motion exercises may not be the priority instruction for discharge teaching. Exercise recommendations should be individualized and may include aerobic and resistance training based on the client's condition and functional status.

A. Initiating teaching for client care after discharge is not within the scope of practice for a practical nurse (PN). Teaching, particularly initial or complex teaching, is a responsibility of the registered nurse (RN) because it requires assessment, planning, and evaluation of the client’s understanding.

B. Evaluating and updating plans of care is a responsibility of the RN. This activity requires critical thinking and clinical judgment to assess client progress and make adjustments to care plans, which are outside the PN’s scope of practice.

C. Performing the initial sterile wound care for surgical clients should be done by the RN. The initial wound care requires assessment of the wound’s condition, which is a task that involves critical thinking and is beyond the PN’s scope.

D. Validating prescribed intravenous flow rates is an appropriate task for the PN. This task is within their scope of practice as it involves verifying that the IV is running as prescribed but does not require the higher-level assessment and critical thinking skills reserved for the RN.