The nurse is teaching a client about fluid and electrolyte balance.
Which electrolyte should the nurse say is the most abundant in the extracellular fluid?

Choice A rationale

Bathing is generally discouraged for individuals prone to urinary tract infections because sitting in soapy water can allow bacteria to enter the urethra. Showering is preferred as it washes bacteria away from the urethral opening. The proximity of the anus to the urethra in females increases the risk of Escherichia coli migration. Therefore, recommending baths over showers is scientifically incorrect for infection prevention and represents a misunderstanding of hygiene-related risks.

Choice B rationale

A post-void residual of 50 milliliters or less is considered a normal finding, indicating that the bladder is emptying effectively. High residual volumes, typically exceeding 100 milliliters, create a stagnant pool of urine that serves as a medium for bacterial growth. Efficient bladder emptying is a primary defense mechanism against infection. Since 50 milliliters is within the healthy range, it is not associated with the development of a urinary tract infection.

Choice C rationale

Urinary tract infections are classified based on their location within the system. Lower infections, such as cystitis, involve the bladder and urethra, while upper infections, like pyelonephritis, involve the ureters and the kidneys. Bacteria usually ascend from the lower tract to the upper tract. Understanding this distinction is critical because upper tract infections are more severe and can lead to systemic sepsis or permanent renal scarring if not treated promptly.

Choice D rationale

Individuals with diabetes mellitus are actually at a significantly higher risk for urinary tract infections. High glucose levels in the urine, known as glycosuria, provide an ideal nutrient source for pathogens like bacteria and yeast. Additionally, diabetic neuropathy can lead to neurogenic bladder and incomplete emptying. Suggesting that infections are uncommon in this population contradicts established pathophysiology regarding metabolic disorders and their impact on immune function and urinary health.

Choice A rationale

Evaluating a client's response to medication is a complex nursing function that requires clinical judgment, knowledge of pharmacology, and assessment skills. This task involves comparing the expected therapeutic effects with the actual outcomes and identifying any adverse reactions. Because evaluation is a core component of the nursing process (ADPIE), it cannot be delegated to unlicensed assistive personnel. The registered nurse is responsible for interpreting data and making decisions about the effectiveness of the treatment plan for the patient.

Choice B rationale

Taking and reporting routine vital signs is a standard task that can be safely delegated to unlicensed assistive personnel in stable situations. This task is procedural and does not require advanced clinical judgment to perform the measurement itself. However, the nurse remains responsible for interpreting the results and determining if they are within normal limits for the specific patient. Normal ranges include blood pressure < 120/80 mmHg, heart rate 60 to 100 beats, and respiratory rate 12 to 20.

Choice C rationale

Developing a teaching plan for discharge involves assessing the learner's needs, identifying goals, and selecting appropriate educational strategies. This is a highly individualized process that requires professional knowledge of disease processes and teaching-learning principles. Unlicensed personnel do not have the training to create or modify care plans or educational materials. The registered nurse must lead the discharge planning process to ensure that the patient receives accurate and comprehensive information necessary for safe care at home.

Choice D rationale

Assessing a client's level of pain after surgery is a professional nursing responsibility that involves more than just asking for a number on a scale. It requires an understanding of the surgical procedure, potential complications, and the timing of analgesic administration. The nurse must interpret the pain within the clinical context of the patient's recovery. Since assessment is the first step of the nursing process and requires clinical judgment, it is not appropriate to delegate to unlicensed staff.