A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
Palpate the degree of edema.
Regulate IV pump fluid rate.
Measure the client's daily weight.
Assess the client's vital signs.
The Correct Answer is C
A. Palpate the degree of edema. This is incorrect because palpating the degree of edema requires clinical judgment and skill, which are beyond the scope of practice of an AP.
B. Regulate IV pump fluid rate. This is incorrect because regulating IV pump fluid rate is a nursing responsibility that involves calculating and adjusting the infusion rate based on the client's condition and orders.
C. Measure the client's daily weight. This is correct because measuring the client's daily weight is a routine task that can be delegated to an AP, as long as the nurse provides clear instructions and monitors the results. The client's daily weight is an indicator of fluid balance and can help evaluate the effectiveness of treatment.
D. Assess the client's vital signs. This is incorrect because assessing the client's vital signs requires interpretation and analysis of data, which are nursing functions that cannot be delegated to an AP.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A is incorrect because tinnitus, or ringing in the ears, is not an adverse effect of captopril, but rather a symptom of other conditions such as ear infection, noise exposure, or medication toxicity.
B is correct because cough is a serious adverse effect of captopril, which is an angiotensin-converting enzyme (ACE) inhibitor that can cause angioedema, or swelling of the airways.
C is incorrect because polyuria, or excessive urination, is not an adverse effect of captopril, but rather a symptom of other conditions such as diabetes mellitus, diabetes insipidus, or diuretic use.
D is incorrect because blurred vision is not an adverse effect of captopril, but rather a symptom of other conditions such as eye strain, refractive error, or cataract.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
The client is at risk for experiencing electrolyte imbalance due to the vomiting. Persistent vomiting during pregnancy, especially with significant weight loss, can lead to electrolyte imbalances such as hypokalemia, hyponatremia, or metabolic alkalosis. This can result from the body's inability to retain essential minerals and fluids. The client’s reported diet of minimal food intake, primarily consisting of toast and pretzels, indicates inadequate nutrition and potential for further exacerbation of these imbalances.
The significant weight loss of 6.8 kg (15 lb) within a month and continuous nausea and vomiting are concerning symptoms that warrant immediate medical evaluation. The nurse’s advice to seek a provider’s assessment underscores the need for timely intervention to address potential complications, ensure maternal and fetal health, and possibly prescribe antiemetic medications or other treatments to manage symptoms.
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