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A nurse is caring for a client in an emergency department (ED).

Exhibits
The nurse reviews the Nurses’ Notes from Day 1 at 1100.
Select 4 tasks the nurse should plan to delegate to the assistive personnel.

Perform daily weights.

Identify thoughts that reinforce disordered eating patterns.

Accompany the client to the restroom following meals.

Observe the client during meals.

Consult the dietitian to determine the client’s caloric intake.

Use cognitive behavioral techniques to address the client’s behavior.

Discuss measures to assist the client to develop a positive body image.

Encourage the client to discuss feelings of new eating patterns.

Check the client’s vital signs.

Answer and Explanation

Correct Answer : A,C,D,I

A. Perform daily weights: Daily weights are important to monitor progress and detect fluid or nutritional changes. This routine, non-invasive task is appropriate for delegation to assistive personnel (AP) under nurse supervision.

B. Identify thoughts that reinforce disordered eating patterns: Requires therapeutic communication and assessment, which are nursing responsibilities. Not appropriate for delegation to AP.

C. Accompany the client to the restroom following meals: Clients with bulimia are at risk of vomiting or purging after eating. Having an AP accompany the client helps prevent self-induced vomiting and ensures compliance with the treatment plan. The AP should report any unusual behavior to the nurse.

D. Observe the client during meals: Monitoring during meals ensures the client eats appropriately and avoids concealing or discarding food. This is a behavioral safety measure that can be delegated, while the nurse focuses on therapeutic interventions.

E. Consult the dietitian to determine the client’s caloric intake: Consulting other team members is a nursing role, involving coordination of interdisciplinary care.

F. Use cognitive behavioral techniques to address the client’s behavior: CBT and psychotherapy require specialized knowledge and are conducted by nurses or mental health professionals, not assistive personnel.

G. Discuss measures to assist the client to develop a positive body image: Involves therapeutic communication and counseling, not within the AP’s scope.

H. Encourage the client to discuss feelings of new eating patterns: Addressing emotions and behavioral change is a therapeutic intervention requiring nursing judgment.

I. Check the client’s vital signs: Vital signs provide data about orthostatic hypotension, dehydration, or arrhythmia risk. The AP can collect this data, while the nurse evaluates and interprets the results.

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Correct Answer is ["A","B","E","F"]

Explanation

A. ECG: The presence of premature ventricular contractions (PVCs) indicates cardiac irritability, often due to hypokalemia, and requires immediate follow-up to prevent arrhythmias.

B. Syncope: Syncope may result from electrolyte imbalance or cardiac dysrhythmia, both of which can be life-threatening in clients with bulimia nervosa.

C. Oxygen saturation: SpO₂ is 100% on room air, within normal range.

D. Blood pressure: Orthostatic hypotension (92/65 standing) is mild and expected in clients with electrolyte imbalance, but it is not the most critical finding compared to cardiac risks.

E. Albumin: Low albumin (2.6 g/dL) indicates malnutrition and poor protein intake, requiring dietary intervention.

F. Potassium: Hypokalemia (3 mEq/L) is a critical finding due to increased risk of cardiac dysrhythmias and muscle weakness; immediate replacement is required.

A. Obtain a 24 hr urine specimen B. Monitor intake and output hourly C. Administer betamethasone D. Provide a low-stimulation environment E. Give antihypertensive medication F. Maintain bedrest G. Perform a vaginal examination every 12 hr.

Correct Answer is ["B","C","D","E","F"]

Explanation

Rationale

A. Obtain a 24 hr urine specimen: This is the gold standard for quantifying proteinuria and diagnosing preeclampsia, but a rapid 3+ protein dipstick and severe symptoms/lab findings have already established the diagnosis of severe preeclampsia/HELLP. Treatment (magnesium sulfate, blood pressure control, and preparation for delivery) should not be delayed to wait for a 24-hour collection.

B. Monitor intake and output hourly: Clients with preeclampsia are at risk for renal impairment and fluid overload due to vasospasm and endothelial injury. Hourly monitoring ensures adequate renal perfusion (goal urine output ≥30 mL/hr) and prevents complications like pulmonary edema.

C. Administer betamethasone: At 31 weeks’ gestation, preterm delivery is likely if maternal or fetal status deteriorates. Betamethasone promotes fetal lung maturity, reducing the risk of respiratory distress syndrome in the newborn.

D. Provide a low-stimulation environment: A quiet, dimly lit room minimizes external triggers that can increase CNS irritability and lower the seizure threshold in severe preeclampsia. This is essential for preventing eclampsia.

E. Give antihypertensive medication: Severe BP readings (≥160/110 mm Hg) require prompt pharmacologic intervention (e.g., labetalol, hydralazine) to reduce the risk of stroke or placental abruption while maintaining uteroplacental perfusion.

F. Maintain bedrest: Activity restriction (preferably left lateral position) enhances uteroplacental blood flow and decreases BP. It also helps prevent falls or injury if the client becomes symptomatic or experiences a seizure.

G. Perform a vaginal examination every 12 hr: This is contraindicated in clients with preeclampsia who are not in active labor. Vaginal examinations may induce uterine contractions and increase infection risk without clinical benefit. Cervical assessment should only be done if delivery is imminent or indicated by the provider.

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A nurse is caring for a client in an emergency department (ED). Exhibits The nurse reviews the Nurses’ Notes from Day 1 at 1100. Select 4 tasks the nurse should plan to delegate to the assistive personnel.

Nursing Test Bank

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Correct Answer is ["A","B","E","F"]

Explanation

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Correct Answer is ["B","C","D","E","F"]

Explanation

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A nurse is caring for a client in an emergency department (ED).

Exhibits
The nurse reviews the Nurses’ Notes from Day 1 at 1100.
Select 4 tasks the nurse should plan to delegate to the assistive personnel.