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

Explanation

- A. Radial vein of the inner arm. This is correct because this site is easily accessible, has good blood flow, and has less risk of complications such as infection, thrombosis, or infiltration.

- B. Great saphenous vein of the leg. This is incorrect because this site is not recommended for older adults due to poor circulation, increased risk of thrombophlebitis, and difficulty in monitoring.

- C. Dorsal plexus vein of the foot. This is incorrect because this site is prone to edema, infection, and injury, and can interfere with mobility and comfort.

- D. Basilic vein of the hand. This is incorrect because this site is more painful, has smaller veins, and can cause nerve damage or occlusion if not inserted carefully.

A. Ensure that the side rails are up on the client's bed. B. Ambulate the client every 4 hr. C. Check the fetal heart rate twice daily. D. Provide the client with a low-protein diet.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should ensure that the side rails are up on the client's bed. This action is essential for the safety of the client with severe preeclampsia, as it prevents accidental falls or injuries. Preeclampsia is a hypertensive disorder of pregnancy characterized by high blood pressure and signs of organ damage, and it poses significant risks to both the mother and the fetus. By keeping the side rails up, the nurse can minimize the risk of falls and ensure the client's safety while in bed.

Choice B rationale:

Ambulating the client every 4 hours is not appropriate for a pregnant woman with severe preeclampsia. Preeclampsia can cause high blood pressure, swelling, and proteinuria. It is a serious condition that requires close monitoring and strict bed rest to prevent complications such as seizures or eclampsia. Ambulation may increase the risk of falls and is contraindicated in this situation.

Choice C rationale:

Checking the fetal heart rate twice daily is important in the care of a pregnant client with severe preeclampsia. However, ensuring the client's safety by keeping the side rails up on the bed takes priority. While monitoring the fetal heart rate is crucial for assessing the baby's well-being, it does not address the immediate safety concerns of the client, which can be addressed by maintaining the side rails up.

Choice D rationale:

Providing the client with a low-protein diet is not the correct action for a pregnant woman with severe preeclampsia. In fact, pregnant women with preeclampsia are often advised to increase their protein intake to help manage their condition. A low-protein diet can lead to malnutrition and may not provide the necessary nutrients for both the mother and the developing fetus. The primary focus should be on bed rest, monitoring vital signs, and managing symptoms to prevent complications.

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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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