The practical nurse (PN) is implementing a nursing care plan that requires daily weights. Which factor is most important for the PN to consider regarding daily weights?
The amount of fluid the client drank today.
When the client wants to be weighed.
When the client was last weighed.
The amount of food the client ate today
The Correct Answer is C
A. The amount of fluid the client drank today: Although fluid intake affects weight, daily weights are intended to reflect overall fluid and nutritional changes over time, not just today's intake. Monitoring intake is important but not the most critical factor in conducting daily weights consistently.
B. When the client wants to be weighed: While respecting the client's preferences is important for cooperation, clinical accuracy requires consistency in timing and conditions, not simply weighing at the client's preferred time.
C. When the client was last weighed: Knowing when the client was last weighed ensures consistency and accuracy for monitoring trends. Daily weights should be taken at the same time each day, ideally in the morning before eating and after voiding, to accurately track fluid balance and body mass changes.
D. The amount of food the client ate today: Food intake affects weight slightly, but the purpose of daily weights is to detect significant changes, such as fluid retention or loss. Weighing under consistent conditions matters more than focusing on the day's food intake.
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Related Questions
Correct Answer is D
Explanation
A. Notify the nursing board: Reporting to the nursing board is necessary for ongoing professional accountability but is not the immediate first step. The priority is to ensure the safety of clients by addressing the situation within the facility first.
B. Submit an incident report: An incident report documents the event, but it should be completed after immediate concerns for client safety are addressed. It is not the first action when dealing with an impaired nurse.
C. Email the nurse manager: Emailing the nurse manager may delay the response. Immediate verbal communication with someone in a supervisory role is essential to remove the impaired nurse from client care duties without delay.
D. Inform the charge nurse: Informing the charge nurse immediately is the priority because the charge nurse has the authority to intervene quickly, ensure the impaired nurse is removed from duty, and maintain patient safety. This allows for appropriate administrative steps to follow afterward.
Correct Answer is D
Explanation
A. Wear a surgical mask during all client contact: While wearing a surgical mask protects the nurse from inhaling respiratory droplets, it is equally important to prevent the client from spreading droplets to others, especially when moving outside the room.
B. Use an isolation gown when providing client care: An isolation gown protects against contact transmission rather than droplet transmission. Influenza spreads primarily through respiratory droplets, so gowns are not the primary measure to prevent its spread.
C. Determine if the client's room has negative airflow: Negative airflow rooms are necessary for airborne infections like tuberculosis, not for droplet-spread infections such as influenza. Standard precautions for influenza focus more on masking and hygiene practices.
D. Place a mask on the client if the client leaves the room: Masking the client when outside their room helps contain respiratory droplets, minimizing the risk of infecting others. This intervention is crucial in controlling the spread of influenza within healthcare settings.
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