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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
"Use a cane when walking to maintain your balance" is the correct statement Multiple sclerosis (MS) is a chronic autoimmune condition that affects the central nervous system, leading to various neurological symptoms. Mobility and balance issues are common among individuals with MS, and using a cane can be helpful in providing stability and support while walking. It can also reduce the risk of falls and improve the client's overall safety and confidence when ambulating.
Choice B reason:
"Plan to take a hot bath once a week to reduce stress” is not appropriate statement. Heat sensitivity is a common symptom in individuals with MS, and exposure to heat, such as hot baths or saunas, can exacerbate MS symptoms. It is generally advisable for individuals with MS to avoid excessive heat exposure as it can worsen fatigue and other neurological symptoms.
Choice C reason:
"Engage in a rigorous exercise program to maintain muscle tone" is not appropriate. While exercise is beneficial for individuals with MS, particularly in maintaining muscle strength and flexibility, it is essential to avoid a rigorous or overly strenuous exercise program. High-intensity exercise may lead to increased fatigue and exacerbation of MS symptoms. A personalized exercise plan that considers the individual's specific abilities and limitations is recommended.
Choice D reason
"Place a scatter rug in your bathroom to prevent falling" is not appropriate statement. Placing a scatter rug in the bathroom is not advisable, especially for individuals with mobility and balance issues like those with MS. Scatter rugs can create tripping hazards and increase the risk of falls. It is essential to keep the bathroom floor clear and use non-slip mats to improve safety.
Correct Answer is ["A","B"]
Explanation
A: Correct. Broccoli is a vegetable that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.
B: Correct. Yogurt is a dairy product that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.
C: Incorrect. Pepperoni pizza contains pepperoni, cheese, and tomato sauce, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.
D: Incorrect. Cream cheese is a dairy product that contains tyramine, which can interact with phenelzine and cause a hypertensive crisis.
E: Incorrect. Bologna sandwich contains bologna, bread, and mayonnaise, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.
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