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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Incorrect. The nurse should assess the client's IV site every hour to prevent infection and phlebitis.

B. Incorrect. The nurse should check the client's WBC count every day to monitor for signs of infection or bone marrow suppression.

C. Correct. The nurse should monitor the client's mouth every 8 hr for signs of oral candidiasis, which is a common fungal infection in immunosuppressed clients.

D. Incorrect. The nurse should change the client's IV tubing every 24 hr to reduce the risk of bacterial contamination.

A. Documents client tasks upon completion B. Starts a task then determines what supplies are needed C. Completes a client assessment while infusing an IV antibiotic over 30 min D. Returns to the nurses' station after completing several tasks in the same location

Correct Answer is B

Explanation

A is incorrect because documenting client tasks upon completion is an appropriate action by the newly licensed nurse that demonstrates accuracy and timeliness of documentation.

B is correct because starting a task then determining what supplies are needed is an inappropriate action by the newly licensed nurse that indicates poor planning and organization skills.

C is incorrect because completing a client assessment while infusing an IV antibiotic over 30 min is an appropriate action by the newly licensed nurse that demonstrates efficient use of time and multitasking ability.

D is incorrect because returning to the nurses' station after completing several tasks in the same location is an appropriate action by the newly licensed nurse that demonstrates effective prioritization and delegation skills.

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