The nurse is caring for a client with a fluid volume deficit and hypovolemia. What actions can the nurse take without a physician's order?
Daily weights, vital signs and fluid intake and output
Monitoring temperature, fluid intake and output and administering IV fluids
Auscultation of lung sounds. Monitoring urine color and placing an indwelling urinary catheter in the client
Daily weights, diuretics and waist measurement
The Correct Answer is A
A. Daily weights, vital signs, and fluid intake and output: These are essential nursing assessments and interventions that can be implemented without a physician's order to monitor the client's fluid volume deficit and hypovolemia. Daily weights help assess changes in fluid status, vital signs provide information on the client's hemodynamic stability, and monitoring fluid intake and output helps track fluid balance.
B. Monitoring temperature, fluid intake and output, and administering IV fluids: While monitoring temperature and fluid intake and output are important aspects of nursing care, administering IV fluids typically requires a physician's order, especially in the context of hypovolemia. The nurse should collaborate with the healthcare team to determine the need for IV fluid therapy.
C. Auscultation of lung sounds, monitoring urine color, and placing an indwelling urinary catheter in the client: Auscultation of lung sounds and monitoring urine color are relevant assessments for fluid volume status, but placing an indwelling urinary catheter typically requires a physician's order unless there is a specific nursing protocol in place allowing nurses to insert catheters under certain circumstances.
D. Daily weights, diuretics, and waist measurement: While daily weights are appropriate for assessing fluid status, administering diuretics should be based on a physician's order and assessment findings. Waist measurement is not typically used to assess fluid volume deficit and hypovolemia.
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Correct Answer is B
Explanation
A. Sorry: Expressing regret or remorse for an error is important, but it does not fully encompass the ethical responsibility demonstrated in this scenario. While acknowledging the mistake and feeling sorry is essential, the nurse's primary ethical obligation lies in taking appropriate action to rectify the error and prevent harm to the client.
B. Accountable: Being accountable involves taking responsibility for one's actions, including acknowledging errors, reporting them promptly, and taking corrective measures. In this scenario, the nurse demonstrates accountability by recognizing the administration of a wrong dose of medication and promptly informing the supervisor. Accountability is a fundamental ethical principle in healthcare that promotes transparency, integrity, and patient safety.
C. Altruistic: Altruism involves acting in the best interests of others, often selflessly and without expecting personal gain. While reporting errors and ensuring patient safety can be considered altruistic actions, the primary ethical behavior demonstrated in this scenario is accountability, as the nurse takes responsibility for the medication error.
D. Just: Justice in healthcare refers to fairness, equity, and adherence to ethical principles in the distribution of resources and provision of care. While ensuring justice is an important ethical consideration in healthcare, it is not directly applicable to the nurse's behavior in this scenario. The primary ethical principle demonstrated here is accountability, as the nurse takes responsibility for the medication error and acts to address it appropriately.
Correct Answer is A
Explanation
A. Daily weights, vital signs, and fluid intake and output: These are essential nursing assessments and interventions that can be implemented without a physician's order to monitor the client's fluid volume deficit and hypovolemia. Daily weights help assess changes in fluid status, vital signs provide information on the client's hemodynamic stability, and monitoring fluid intake and output helps track fluid balance.
B. Monitoring temperature, fluid intake and output, and administering IV fluids: While monitoring temperature and fluid intake and output are important aspects of nursing care, administering IV fluids typically requires a physician's order, especially in the context of hypovolemia. The nurse should collaborate with the healthcare team to determine the need for IV fluid therapy.
C. Auscultation of lung sounds, monitoring urine color, and placing an indwelling urinary catheter in the client: Auscultation of lung sounds and monitoring urine color are relevant assessments for fluid volume status, but placing an indwelling urinary catheter typically requires a physician's order unless there is a specific nursing protocol in place allowing nurses to insert catheters under certain circumstances.
D. Daily weights, diuretics, and waist measurement: While daily weights are appropriate for assessing fluid status, administering diuretics should be based on a physician's order and assessment findings. Waist measurement is not typically used to assess fluid volume deficit and hypovolemia.
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