A nurse asks the unlicensed assistive personnel (UAP) to assist in determining the fluid status of a client. Which of the following actions should the nurse delegate to the UAP? (Select All That Apply)

Record intake and output

Assess bowel sounds

Obtain routine vital signs

Document the presence of edema

Answer and Explanation

Correct Answer : A,C,D

A. Record intake and output: This task is within the UAP's scope of practice as it involves documenting fluid balance.

B. Assess bowel sounds: This task requires clinical judgment and assessment skills and should be performed by a licensed nurse.

C. Obtain routine vital signs: This is appropriate for the UAP to perform, as it involves routine measurements that do not require clinical assessment.

D. Document the presence of edema: The UAP can document observable findings such as edema, which is within their scope of practice.

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Correct Answer is D

Explanation

A. Level of consciousness: While important, it follows the assessment of vital signs to ensure the client's overall stability.
B. Condition of drains: This is relevant but not as immediate as assessing the stability of vital signs.
C. Appearance of the surgical dressing: This is important but secondary to ensuring the client’s vital signs are stable.
D. Stability of vital signs: This is the most critical next assessment after ensuring a patent airway, as vital signs reflect the client's immediate physiological status and stability.

A. A 47-year-old client who reports two loose stools with a serum sodium of 139 mmol/L B. A 71-year-old client with a calcium level of 8.9 mg/dL and a negative Trousseau sign C. A 52-year-old client with fluid volume excess and BUN of 18 mg/dL D. A 60-year-old client with a serum potassium of 3.2 mEq/L and heart palpitations

Correct Answer is D

Explanation

A. A 47-year-old client who reports two loose stools with a serum sodium of 139 mmol/L: Although diarrhea can lead to electrolyte imbalances, a serum sodium level of 139 mmol/L is within normal range, so this client is not the highest priority.
B. A 71-year-old client with a calcium level of 8.9 mg/dL and a negative Trousseau sign: A calcium level of 8.9 mg/dL is slightly low but not critically low, especially with a negative Trousseau sign. This client is stable compared to others.
C. A 52-year-old client with fluid volume excess and BUN of 18 mg/dL: A BUN of 18 mg/dL indicates mild elevation, and fluid volume excess can be managed with adjustments in treatment; this client does not require immediate priority.
D. A 60-year-old client with a serum potassium of 3.2 mEq/L and heart palpitations: A potassium level of 3.2 mEq/L indicates hypokalemia, which can cause serious cardiac issues and symptoms like palpitations. This client requires urgent attention to address the potential risk of cardiac complications.

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A nurse asks the unlicensed assistive personnel (UAP) to assist in determining the fluid status of a client. Which of the following actions should the nurse delegate to the UAP? (Select All That Apply)

Nursing Test Bank

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