The unlicensed assistive personnel (UAP) reports to the nurse that a male client with fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the nurse implement?

Ask the client why he does not want to be weighed.

Instruct the UAP to weigh the client using a.

Direct the UAP to delay weighing the client until later.

Document that the client refused daily weights.

Answer and Explanation

The Correct Answer is B

Choice A Reason: Asking the client why he does not want to be weighed is not a priority action because it does not address the need to obtain his daily weight. The nurse should first try to find a way to weigh the client without causing him discomfort or distress.

Choice B Reason: This is the correct answer because weighing the client using a bed scale can avoid the need for

transferring him from the bed to a standing scale, which may be difficult or painful for him. The bed scale can provide an accurate measurement of his weight and help monitor his fluid status.

Choice C Reason: Directing the UAP to delay weighing the client until later is not an appropriate action because it may result in missing or inaccurate data. The nurse should ensure that the client is weighed at the same time every day, preferably in the morning, before any fluid intake or output.

Choice D Reason: Documenting that the client refused daily weights is not an adequate action because it does not reflect the nurse's responsibility to provide quality care for the client. The nurse should try to resolve the issue of weighing the client and documenting the outcome and any interventions.

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Correct Answer is B

Explanation

Choice A Reason: Beginning initial sterile wound care for surgical clients is a nursing intervention that requires clinical judgment and cannot be delegated to the PN. The PN may assist with wound care after the initial dressing change, but the RN is responsible for assessing the wound and initiating the plan of care.

Choice B Reason: Validating prescribed intravenous flow rates is a routine task that does not require clinical judgment and can be delegated to the PN. The PN has the knowledge and skill to check the IV orders, calculate the drip rate, and monitor the infusion.

Choice C Reason: Determining the need for urinary catheterizations is a nursing assessment that requires clinical judgment and cannot be delegated to the PN. The PN may perform urinary catheterizations as ordered by the physician, but the RN is responsible for evaluating the indication, risk, and benefit of the procedure.

Choice D Reason: Receiving a postoperative client and conducting the assessment is a nursing intervention that requires clinical judgment and cannot be delegated to the PN. The RN is responsible for receiving reports from the operating room, assessing the client's status, identifying potential complications, and initiating the plan of care.

A. The client two days post-thyroidectomy and is unable to speak clearly due to laryngeal nerve damage. B. The client newly diagnosed with hypothyroidism and who is to receive the first dose of levothyroxine. C. The client with diabetes and has an elevated serum glycosylated Hgb (Hgb A1C). D. The client exhibiting signs of Addison's crisis after corticosteroids were discontinued.

Correct Answer is A

Explanation

Choice A Reason: This client has a potential airway obstruction and needs close monitoring by the nurse. Laryngeal nerve damage can cause vocal cord paralysis, which can lead to respiratory distress and aspiration.

Choice B Reason: This client needs education on the medication and its side effects, but this can be done by the PN under the supervision of the nurse. Levothyroxine is a synthetic thyroid hormone that replaces deficient hormones in hypothyroidism.

Choice C Reason: This client needs ongoing management of diabetes, but this can be done by the PN under the supervision of the nurse. Glycosylated Hgb (Hgb A1C) is a measure of the average blood glucose level over the past three months.

Choice D Reason: This client has a life-threatening condition that requires immediate treatment with corticosteroids, but this can be done by the PN under the supervision of the nurse. Addison's crisis is a severe form of adrenal insufficiency that causes hypotension, shock, and electrolyte imbalance.

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The unlicensed assistive personnel (UAP) reports to the nurse that a male client with fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the PN?

Correct Answer is B

Explanation

In assigning client care to a nurse and a practical nurse (PN), it is most important to assign which client to the nurse?

Correct Answer is A

Explanation

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