Which four of the patient orders can be delegated to the nursing aide? Select all four that apply.
Insert indwelling urinary catheter.
Monitor IV D5 1/2 NS with 20 mEq KCl at 75 m/hr.
Empty urinary catheter and measure the output.
Collect a stool sample for occult blood testing.
Daily weights.
Notify the MD of any signs of bleeding.
Vital signs every 4 hours.
Correct Answer : C,D,E,G
Choice A reason: Insert indwelling urinary catheter. This task requires clinical judgment, sterile technique, and expertise. It is an invasive procedure that should be performed by a registered nurse or a physician.
Choice B reason: Monitor IV D5 1/2 NS with 20 mEq KCl at 75 m/hr. Monitoring IV fluids and medications involves assessing the patient’s response to treatment, recognizing potential complications, and making clinical decisions. This task requires the expertise of a registered nurse.
Choice C reason: Empty urinary catheter and measure the output. This task can be delegated to a nursing aide as it involves routine measurement and documentation, which does not require clinical judgment. It is a simple procedure that can be safely performed by a trained aide.
Choice D reason: Collect a stool sample for occult blood testing. This is a straightforward task that can be delegated to a nursing aide. It involves collecting and labeling the sample correctly, which does not require advanced clinical skills or judgment.
Choice E reason: Daily weights. This task can be safely delegated to a nursing aide. It involves measuring and recording the patient’s weight, which is a routine procedure and does not require clinical judgment.
Choice F reason: Notify the MD of any signs of bleeding. This task involves assessing the patient for signs of bleeding, which requires clinical judgment and should be performed by a registered nurse. The nurse must determine the significance of the findings and communicate them appropriately to the physician.
Choice G reason: Vital signs every 4 hours. Monitoring vital signs is a routine task that can be delegated to a nursing aide. It involves measuring and recording the patient’s blood pressure, heart rate, respiratory rate, and temperature, which does not require advanced clinical skills.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Monitoring potassium levels is essential for various medical conditions, but it is not specifically used to evaluate the effects of therapy for acute pancreatitis. Potassium levels may be monitored to assess overall electrolyte balance and kidney function, but they do not provide direct information about pancreatic inflammation or damage.
Choice B reason: Monitoring lipase levels is crucial in evaluating the effects of therapy for a patient with acute pancreatitis. Lipase is an enzyme produced by the pancreas, and its levels rise significantly during an acute episode of pancreatitis. Elevated lipase levels are a sensitive and specific indicator of pancreatic inflammation and damage. By regularly measuring lipase levels, healthcare providers can assess the severity of the condition, monitor the patient's response to treatment, and make necessary adjustments to the therapeutic regimen.
Choice C reason: Calcium levels are not typically used to evaluate the effects of therapy for acute pancreatitis. Although hypercalcemia (high calcium levels) can be a risk factor for developing pancreatitis, monitoring calcium levels is not a standard method for assessing the effectiveness of treatment for the condition.
Choice D reason: Bilirubin levels are not directly related to the evaluation of therapy for acute pancreatitis. Bilirubin is a breakdown product of hemoglobin and is primarily used to assess liver function and diagnose conditions such as jaundice or liver disease. While liver function tests may be performed in patients with pancreatitis to rule out concurrent liver issues, bilirubin levels alone do not provide information about the effectiveness of therapy for pancreatitis.
Correct Answer is B
Explanation
Choice A reason: Asking the patient why the wandering episodes have occurred might not be effective because patients with Alzheimer's disease often have memory and cognitive impairments that make it difficult for them to understand or articulate the reasons for their behavior. Additionally, it may not address the immediate safety concerns associated with wandering.
Choice B reason: Placing the patient in a room close to the nurse's station is a practical and effective measure to enhance patient safety. Proximity to the nurse's station allows for closer supervision and quicker response if the patient attempts to wander. This action helps prevent potential accidents and ensures that the patient receives timely interventions if needed. It is a proactive approach to managing the wandering behavior commonly seen in patients with Alzheimer's disease.
Choice C reason: Reorienting the patient several times daily is an important aspect of care for individuals with Alzheimer's disease, as it can help reduce confusion and anxiety. However, this alone may not be sufficient to prevent wandering. While reorientation is beneficial, the immediate safety of the patient requires additional measures, such as close supervision.
Choice D reason: Having the family bring in familiar items can provide comfort and a sense of security for the patient, which is important in managing Alzheimer's disease. Familiar objects may help reduce anxiety and agitation, but they do not directly address the safety concerns associated with wandering. This action should be part of a comprehensive care plan that includes measures to prevent wandering and ensure patient safety.
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