A nurse is caring for an infant who is being treated for dehydration. Which of the following findings indicates the treatment is effective?

 

 

 

A. While a blood pressure of 156/90 mm Hg may be elevated, it is not necessarily an indication to withhold propranolol, which is commonly used to treat hypertension.

B. A pulse rate of 54/min suggests bradycardia, which is a potential side effect of propranolol and may warrant withholding the medication.

C. A potassium level of 5.2 mEq/L is within the normal range (3.5-5.0 mEq/L) and is not typically a reason to withhold propranolol.

D. A sodium level of 130 mEq/L is within the normal range (135-145 mEq/L) and is not typically a reason to withhold propranolol.

A. A client with chronic obstructive pulmonary disease who needs guidance on incentive spirometry requires nursing judgment and education to ensure proper technique, so this task is best performed by a nurse.

B. A client who had a myocardial infarction 3 days ago and reports chest discomfort requires assessment and potential intervention by a nurse to address cardiac issues.

C. Assisting a client with toileting typically involves tasks such as transferring, positioning, and providing hygiene assistance, which can be safely delegated to an assistive personnel.

D. Providing a client who has awoken following a bronchoscopy with a drink involves assessing for the absence of nausea or vomiting and ensuring the client can swallow safely, which requires nursing judgment and should be performed by a nurse.