A nurse is training a newly licensed nurse. The newly licensed nurse asks if she can delegate the task of weighing several clients to an assistive personnel (AP). Which of the following responses should the nurse make?
"You can delegate this task if the AP has been trained to use our scales."
"You should not delegate this task because you have the capability to obtain clients' weights.”
"You should not delegate this task because it requires nursing judgment."
"You can delegate this task to an AP for new clients before performing a nursing assessment.”
The Correct Answer is A
A. Weighing clients is within the scope of an assistive personnel’s role, provided they have been properly trained in using facility equipment and understand the procedure. The nurse retains responsibility for ensuring the accuracy of the data and interpreting it.
B. This response focuses on the nurse’s ability rather than appropriate delegation. Delegating tasks helps manage time and resources effectively when delegation is safe and appropriate.
C. Weighing clients does not require nursing judgment; it is a routine, stable task that is appropriate for delegation under the right conditions.
D. Weights obtained on new clients may be needed before a full nursing assessment, but initial assessments must be performed by a nurse, not delegated to APs.
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Related Questions
Correct Answer is B
Explanation
A. Ibuprofen: This NSAID can irritate the gastric lining and increase the risk of bleeding, making it inappropriate for clients with a history of peptic ulcers.
B. Acetaminophen: It is not an NSAID and does not affect the gastrointestinal lining, making it a safer option for pain relief in clients with peptic ulcer disease.
C. Ketorolac: Like other NSAIDs, ketorolac increases the risk of gastric bleeding and should be avoided in clients with peptic ulcers.
D. Aspirin: Aspirin is an NSAID and antiplatelet agent that can worsen peptic ulcers and increase bleeding risk, so it should not be used in this client.
Correct Answer is A
Explanation
A. “Rise slowly when getting out of bed.": Furosemide is a loop diuretic that can cause orthostatic hypotension due to fluid loss. Teaching the client to rise slowly helps prevent dizziness and falls associated with sudden position changes.
B. "Eat foods that are high in sodium.": Sodium intake should be limited in clients with heart failure, as high sodium can worsen fluid retention and counteract the effects of diuretics like furosemide.
C. “Taking furosemide can cause you to be overhydrated.": Furosemide increases urine output and poses a risk of dehydration, not overhydration. Monitoring fluid balance is essential during treatment.
D. "Taking furosemide can cause your potassium levels to be high.": Furosemide can lead to hypokalemia (low potassium), not hyperkalemia. Clients may need potassium supplementation or dietary adjustments to prevent electrolyte imbalance.
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