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
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The correct answer is Choice A.
Choice A rationale: Forming a committee of staff members to investigate current staffing issues is the first step the nurse manager should take. This is because it is important to understand the root cause of the problem before implementing any changes. By forming a committee, the nurse manager can gather different perspectives and insights from the staff members who are directly affected by the staffing issues. This will help in identifying the specific problems and coming up with effective solutions. Furthermore, involving the staff in the decision-making process can increase their acceptance of the changes and reduce resistance.
Choice B rationale: Providing support to staff members who are resistant to staffing changes is an important step, but it should not be the first action. Before providing support, the nurse manager needs to understand the specific issues causing the resistance. This can be achieved by forming a committee of staff members to investigate the staffing issues.
Choice C rationale: Scheduling a staff meeting to present the different options to staff members is a crucial step in the process. However, this should be done after the nurse manager has a clear understanding of the staffing issues and has identified potential solutions. Presenting options without first understanding the problem may lead to ineffective solutions and increased resistance from staff members.
Choice D rationale: Giving the staff members advance written notice of staffing changes is a necessary step to ensure transparency and to give staff members time to adjust. However, this should be done after the nurse manager has identified the staffing issues, explored potential solutions, and decided on the changes to be implemented.
Correct Answer is ["B","C","E","F"]
Explanation
- A. Bowel sounds are hypoactive in all four quadrants, which is expected after an appendectomy due to anesthesia and decreased peristalsis. This is not a finding that needs to be reported to the provider.
- B. Oxygen saturation is 93% on room air, which is below the normal range of 95% to 100%. This could indicate impaired gas exchange, respiratory depression, or infection. This is a finding that needs to be reported to the provider.
- C. Nausea is a common feature of appendicitis and should go away with appendectomy. This finding should, therefore, be reported to the healthcare provider.
- D. Vomiting is also a common side effect of morphine and anesthesia, and can be managed with antiemetics and fluids. This is not a finding that needs to be reported to the provider unless it persists or interferes with oral intake.
- E. Pain level is 6 on a scale of 0 to 10.The client received morphine as prescribed at 1815, and the pain level is still significant. This isa finding that needs to be reported to the provider
- F. Heart rate is 110/min, which is above the normal range of 60 to 100/min. This could indicate pain, anxiety, dehydration, infection, or bleeding. This is a finding that needs to be reported to the provider.
- G. Incision characteristics are clean and dry, which is expected after an appendectomy. However, the nurse should monitor for signs of infection such as redness, swelling, warmth, drainage, or odor. This is a finding that needs to be reported to the provider if any signs of infection are present.
- H. Lungs sounds are clear on auscultation, which is expected after an appendectomy. However, the nurse should encourage deep breathing and coughing exercises to prevent atelectasis and pneumonia. This is a finding that needs to be reported to the provider if any abnormal lung sounds are heard such as crackles, wheezes, or diminished breath sounds.
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