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 ["A","C","E"]

Explanation

Since the client is experiencing upper chest discomfort and coughing up sputum, it is important to assess their oxygen saturation level. This finding can provide vital information about the client's respiratory status and the adequacy of their oxygenation.

The client's report of upper chest discomfort and coughing up thick clear sputum should prompt an assessment of their respiratory rate. Abnormal respiratory rates may indicate respiratory distress or compromise, which requires immediate attention.

Assessing the client's current level of consciousness is crucial, as any sudden changes in their mental status may indicate a serious underlying issue. Since the client has a history of Parkinson's disease and reported "feeling bad," it is important to evaluate their neurological status promptly.

The other options listed (tremors, heart rate, and chronic health condition) may also require follow-up, but they are not the most immediate concerns in this situation.

A. Avoid including raw fruits in the client's diet. B. Restrict visits from young children to 2 hr per day. C. Measure the client's temperature once per shift. D. Use disposable gloves from a box outside the client's room.

Correct Answer is A

Explanation

- A. The nurse should discourage raw fruits due to risk of infection.

- B. There is no standard recommendation against exposure to young children.

- C. Incorrect. The nurse should measure the client's temperature at least every 4 hr, or more frequently if indicated because fever is a sign of infection in a client who has neutropenia and requires prompt intervention.

- D. Incorrect. The nurse should use disposable gloves from a box inside the client's room, not outside, to prevent cross-contamination and protect the client from exposure to pathogens.

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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)?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","E"]

Explanation

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

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