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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Related Questions
Correct Answer is {"dropdown-group-1":"C"}
Explanation
Electrolyte imbalance in pregnant clients is often associated with conditions that lead to dehydration and nutritional deficiencies. In this scenario, the key indicators are persistent nausea and significant weight loss.
- Persistent nausea can lead to reduced food and fluid intake. This condition, especially if prolonged, can cause dehydration and electrolyte imbalances due to the loss of essential minerals and nutrients that are not being replenished due to inadequate dietary intake.
- Significant weight loss, particularly the amount described in the scenario (6.8 kg or 15 lb), is a clear sign of inadequate nutritional intake and can further exacerbate the risk of electrolyte imbalance. It indicates that the body is not receiving enough nutrients, which is crucial for maintaining electrolyte balance.
The other options, while related to diet and fluid intake, are more specific to the client's eating habits and do not directly point to the primary cause of potential electrolyte imbalance in the context of this scenario. Therefore, the most comprehensive and medically relevant choice is (A) Persistent nausea and significant weight loss.
Correct Answer is C
Explanation
Choice A rationale:
Providing postmortem care for a client who has recently died does not require immediate intervention by the charge nurse, as it is a standard nursing responsibility to provide postmortem care with dignity and respect to the deceased client. The AP can proceed with this task independently.
Choice B rationale:
Performing a simple dressing change on a client's foot is within the scope of practice for an assistive personnel (AP) and does not require immediate intervention by the charge nurse, assuming the AP is competent and trained to perform this task.
Choice C rationale:
Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile is not sufficient. Alcohol is not effective against C. Difficile spores.
Choice D rationale:
Clean gloves are sufficient for this task, as they do provide adequate protection against the transmission of infections.
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