A nurse is planning to delegate the fasting blood glucose testing for a client who has diabetes mellitus to an assistive personnel (AP). Which of the following actions should the nurse take?

Have the AP check the medical record for prior blood glucose test results.

Assign the AP to ask the client if she has taken her antidiabetic medication today.

Determine if the AP has the skills to perform the test.

Help the AP perform the blood glucose test.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Checking the medical record for prior blood glucose test results is a task that can be delegated to the assistive personnel (AP). It provides relevant information for the nurse to assess the client's current condition. However, it is not the most crucial step in ensuring the safe performance of the blood glucose test.

Choice B rationale:

Asking the client if she has taken her antidiabetic medication today is important, but this task is better suited for the nurse, as it requires accurate communication with the client about their medication history and adherence. Delegating this task to the AP may lead to potential misunderstandings or errors in the information provided.

Choice C rationale:

The nurse should determine if the AP has the necessary skills and competence to perform the blood glucose test. Delegating tasks based on the competency of the staff member ensures the safety and well-being of the client. If the AP is not skilled in performing the test, the nurse should assign the task to someone else or perform the test personally.

Choice D rationale:

The nurse should not directly perform the blood glucose test if it can be safely delegated to the AP. Delegating appropriate tasks to competent staff members allows nurses to focus on more complex aspects of client care and ensures efficient use of resources within the healthcare team.

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Correct Answer is A

Explanation

Choice A rationale:

Potato pancakes made from potatoes do not contain gluten, making them suitable for someone with celiac disease. Gluten is a protein found in wheat, barley, and rye, so individuals with celiac disease must avoid foods containing these grains.

Choice B rationale:

Wheat crackers contain gluten and are not appropriate for someone with celiac disease. Avoiding gluten is crucial for individuals with this condition to prevent damage to the small intestine.

Choice C rationale:

White flour tortillas are typically made from wheat flour and contain gluten. Individuals with celiac disease should avoid products made from wheat flour to prevent adverse reactions.

Choice D rationale:

Canned barley soup contains barley, which is a gluten-containing grain. Individuals with celiac disease should avoid barley-based products as they contain gluten.

A. Encourage fluid intake of 2,500 mL/day. B. Maintain the environmental temperature at 16°C to 18°C (60°F to 65°F). C. Immerse the client in cold water. D. Assist the client to ambulate.

Correct Answer is A

Explanation

Choice A rationale:

Encouraging fluid intake of 2,500 mL/day is the correct choice for a client with a fever due to an infection. Adequate hydration is essential in managing fever as it helps to prevent dehydration, maintain electrolyte balance, and support the body's immune response. Increasing fluid intake, preferably water, can also aid in lowering body temperature and promoting overall comfort.

Choice B rationale:

Maintaining the environmental temperature at 16°C to 18°C (60°F to 65°F) is not an appropriate intervention for a client with a fever. While it's essential to keep the client comfortable, adjusting the room temperature within a specific range is not the primary intervention. Focus should be on managing the fever through hydration, antipyretic medications, and addressing the underlying infection.

Choice C rationale:

Immersing the client in cold water is not a recommended intervention for managing fever. Cold water immersion can lead to shock, vasoconstriction, and potentially worsen the condition. It is essential to use methods like tepid sponging or cooling blankets if necessary, but these interventions should be performed under healthcare provider guidance and monitoring.

Choice D rationale:

Assisting the client to ambulate is a general nursing care activity and does not specifically address the fever due to infection. While ambulation is encouraged for many patients to prevent complications related to immobility, it is not the primary intervention for managing fever. The focus should be on hydration and other appropriate measures to reduce fever.

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