Infection prevention strategies include:

Choice A reason:

Monitoring for shortness of breath or fatigue after ambulation is a critical task that requires clinical judgment and assessment skills. Certified Nurse Assistants (CNAs) are trained to assist with basic patient care activities but are not typically trained to assess and interpret clinical symptoms such as shortness of breath or fatigue. These symptoms could indicate serious complications such as pulmonary embolism or cardiac issues, which require immediate attention from a licensed nurse or physician. Therefore, this task is not appropriate for delegation to a CNA.

Choice B reason:

Determining whether the patient is ready to increase activity involves assessing the patient’s overall condition, including their vital signs, pain levels, and physical capabilities. This requires a comprehensive understanding of the patient’s medical history and current status, which falls within the scope of practice of a registered nurse (RN) or licensed practical nurse (LPN). CNAs do not have the training to make such determinations, as it involves critical thinking and clinical decision-making skills. Therefore, this task should not be delegated to a CNA.

Choice C reason:

Obtaining the patient’s blood pressure and pulse rate after ambulation is a task that is appropriate for delegation to a CNA. CNAs are trained to measure and record vital signs, including blood pressure and pulse rate. This task does not require clinical judgment or decision-making, making it suitable for delegation. The CNA can report the findings to the nurse, who can then interpret the results and make any necessary clinical decisions. This delegation allows the nurse to focus on more complex tasks that require their advanced training and expertise.

Choice D reason:

Instructing the patient on how to use an incentive spirometer involves patient education, which is a responsibility that typically falls to licensed nurses. Proper use of an incentive spirometer is crucial for preventing postoperative complications such as atelectasis and pneumonia. Ensuring that the patient understands how to use the device correctly requires not only demonstrating its use but also assessing the patient’s comprehension and ability to perform the task. This level of patient education and assessment is beyond the scope of practice for a CNA.

Choice A reason:

Potassium (K+) level of 5.6 mEq/L is a critical finding that requires immediate follow-up. Hyperkalemia, defined as a potassium level greater than 5.0 mEq/L, can lead to severe cardiac complications, including arrhythmias and cardiac arrest. The patient’s ECG changes, such as alterations in the T wave and PR interval, indicate that the elevated potassium level is already affecting cardiac function. Immediate intervention is necessary to lower the potassium level and prevent life-threatening complications. Normal potassium levels range from 3.5 to 5.0 mEq/L.

Choice B reason:

BP 109/70 is slightly lower than the normal range but not critically low. While it is important to monitor blood pressure, this finding does not require immediate follow-up compared to the other more critical issues. The patient’s blood pressure should be monitored regularly to ensure it does not drop further, but it is not the most urgent concern at this moment. Normal blood pressure is typically around 120/80 mmHg.

Choice C reason:

No nausea and vomiting is a positive finding indicating that the patient is not losing additional fluids and electrolytes through emesis. While it is important to note, it does not require follow-up as it does not pose an immediate risk to the patient’s health. The absence of nausea and vomiting is beneficial but does not address the primary concerns related to fluid and electrolyte imbalances.

Choice D reason:

Watery diarrhea for 3 days is a significant finding that requires follow-up due to the risk of dehydration and electrolyte imbalances. Diarrhea leads to the loss of fluids and essential electrolytes, which can result in complications such as hypovolemia and electrolyte disturbances. The patient’s ongoing diarrhea needs to be managed to prevent further fluid loss and stabilize their condition. This symptom is directly contributing to the patient’s current state of weakness and electrolyte imbalance.

Choice E reason:

Lightheaded when standing up suggests orthostatic hypotension, which can be a result of dehydration or electrolyte imbalances. This symptom indicates that the patient is experiencing hemodynamic instability, likely due to fluid loss from diarrhea. It is important to address this issue to prevent falls and further complications. Managing the underlying cause, such as rehydration and correcting electrolyte imbalances, will help stabilize the patient’s condition.

Choice F reason:

Blood Urea Nitrogen (BUN) level of 30 mg/dL is elevated, indicating impaired kidney function or dehydration. Normal BUN levels range from 6 to 24 mg/dL. An elevated BUN level suggests that the kidneys are struggling to manage the body’s waste products and fluid balance. This finding is critical for understanding the extent of the patient’s fluid and electrolyte imbalances and guiding appropriate interventions. Addressing the elevated BUN is essential for improving renal function and overall patient health.

Choice G reason:

HR 102 is slightly elevated, indicating tachycardia. Normal heart rate ranges from 60 to 100 beats per minute. Tachycardia can be a sign of dehydration, pain, anxiety, or other underlying conditions. In this case, the elevated heart rate is likely related to the patient’s dehydration and electrolyte imbalances. Monitoring and managing the heart rate is important to ensure the patient’s cardiovascular stability. Interventions to correct fluid and electrolyte imbalances will help normalize the heart rate.

Choice H reason:

Lung sounds are clear is an important assessment finding but does not require follow-up in the context of fluid and electrolyte imbalances. Clear lung sounds indicate that the patient is not experiencing respiratory complications such as pulmonary edema or infection. While this is a positive finding, it does not address the immediate concerns related to the patient’s fluid and electrolyte status.