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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 B

Explanation

Choice A rationale:

Almonds are not typically associated with latex allergy or cross-sensitivity. Latex cross-reactivity is more commonly seen with certain fruits such as bananas, avocados, kiwis, and chestnuts.

Choice B rationale:

Bananas are known to be cross-reactive with latex allergy. Individuals allergic to latex are more likely to have allergies to certain fruits, including bananas. This cross-sensitivity occurs due to the structural similarity between latex proteins and proteins found in these fruits.

Choice C rationale:

Hazelnuts are not commonly associated with latex cross-reactivity. While some individuals with latex allergy may also be allergic to hazelnuts, it is not a high-risk food in the context of latex cross-sensitivity.

Choice D rationale:

Strawberries are not typically associated with latex allergy or cross-reactivity. Latex cross-reactivity is more commonly seen with fruits like bananas, avocados, kiwis, and chestnuts. Strawberries are not among the high-risk foods for individuals with latex allergy.

Correct Answer is C

Explanation

How does this make you feel?

  • A. Saying "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 assumption on the client. This option is incorrect.
  • B. Asking "Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, and may make the client feel defensive or ashamed. This option is incorrect.
  • C. Asking "How does this make you feel?" is a therapeutic response, as it encourages the client to express their emotions and shows empathy and interest from the nurse. This option is correct.
  • D. Saying "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 family issues and may increase their guilt or anxiety. This option is incorrect.

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