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 C
Explanation
Choice A rationale:
Fidelity refers to the principle of being loyal, faithful, and keeping promises. It does not specifically relate to providing accurate information about treatment effects. In this scenario, the nurse is discussing the potential adverse effects of a treatment, which falls under the domain of providing accurate and truthful information to the client.
Choice B rationale:
Beneficence is the ethical principle of doing good and promoting the well-being of the patient. While educating the client about potential adverse effects is a form of beneficence, the specific principle demonstrated in this scenario is veracity, which is the duty to tell the truth. The nurse is being truthful about the potential side effect (lightheadedness) while clarifying that it should not affect memory.
Choice C rationale:
Veracity is the ethical principle of truth-telling. In this scenario, the nurse is demonstrating veracity by providing honest and accurate information to the client about the potential adverse effects of transcranial magnetic stimulation. By being truthful, the nurse upholds the ethical principle of veracity.
Choice D rationale:
Autonomy refers to the principle of respecting the patient's right to make decisions about their own healthcare. While respecting autonomy is important, the nurse's action in this scenario specifically pertains to providing accurate information (veracity) rather than solely focusing on the client's decision-making autonomy.
Correct Answer is A
Explanation
- A. Correct. The nurse should turn off the CPM machine during mealtime to allow the client to eat comfortably and prevent aspiration.
- B. Incorrect. The nurse should maintain the client's affected hip in a neutral position to prevent dislocation of the prosthesis and promote healing.
- C. Incorrect. The nurse should not instruct the client how to adjust the CPM settings for comfort, as this could interfere with the prescribed range of motion and speed of the device. The nurse should notify the provider if the client reports discomfort or pain.
- D. Incorrect. The nurse should not store the CPM machine under the client's bed when not in use, as this could pose a safety hazard and damage the device. The nurse should place the CPM machine on a stable surface away from the bed.
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