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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)?

A.

Palpate the degree of edema.

B.

Regulate IV pump fluid rate.

C.

Measure the client's daily weight.

D.

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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Related Questions

Correct Answer is C

Explanation

"How does this make you feel?"

  • A. "I'm sure your family does not want you to die." is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's own assumptions. This choice is incorrect.
  • B. Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, which can increase the client's defensiveness and resistance. This choice is incorrect.
  • C. "How does this make you feel?" is a therapeutic response, as it encourages the client to express and explore their emotions, which can help to build rapport and trust with the nurse. This choice is correct.
  • D. "You should talk to your family about your feelings." is not a therapeutic response, as it implies that the client is responsible for resolving their own problems and that their family is willing and able to listen and support them, which may not be true. This choice is incorrect.

Correct Answer is C

Explanation

Choice A rationale:

Limiting fluid intake to 1 liter per day can lead to dehydration and other health complications. It is important for the client to maintain adequate hydration, especially postpartum. This option is incorrect and potentially harmful.

Choice B rationale:

Manual expression of milk can help relieve engorgement without stimulating further milk production. This method allows the client to express milk as needed. However, it can be done even before engorgment occurs

Choice C rationale:

Wearing a snug-fitting bra can provide support and comfort.

Choice D rationale:

Applying moist heat to the breasts can stimulate milk production and relieve engorgement. However, in this case, the client wants to suppress lactation. Therefore, this option is not appropriate and may have the opposite effect of increasing milk production.

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