The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

A. This is a client care intervention that the PN can assign to the UAP. Transporting a urine culture sample to the laboratory is a routine and non-invasive task that does not require clinical judgment or skill. The UAP should follow the standard precautions and protocols for handling and labeling the specimen.

E. This is a client care intervention that the PN can assign to the UAP. Emptying the bedside drainage unit for a client with an indwelling urinary catheter is a routine and non-invasive task that does not require clinical judgment or skill. The UAP should follow the standard precautions and protocols for emptying, measuring, and recording the urine output.

B. This is not a client care intervention that the PN can assign to the UAP. Obtaining a post-voided residual (PVR) volume is a procedure that requires clinical judgment and skill, as it involves using a bladder scanner or catheterizing the client to measure the amount of urine left in the bladder after voiding. The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.

C.This is not a client care intervention that the PN can assign to the UAP. Teaching the client with fluid restrictions how to measure urine output is an educational activity that requires clinical judgment and skill, as it involves assessing the client's learning needs, providing clear and accurate instructions, and evaluating the client's understanding and compliance. The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.

D.This is not a client care intervention that the PN can assign to the UAP. Irrigating an indwelling urinary catheter for a client with bladder suspension is a procedure that requires clinical judgment and skill, as it involves inserting sterile fluid into the bladder through the catheter to flush out any clots, debris, or bacteria. The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.

When a client's family member expresses concerns about the care provided, it is essential for the nurse to gather more information and understand the specific issues raised. By asking for a description of what happened during the night, the nurse can obtain details about the perceived inadequate care. This allows the nurse to gather accurate information, assess the situation, and address any legitimate concerns.
A. Explaining that all staff are doing their best may not address the specific issues raised by the daughter and may not provide a satisfactory resolution to her concerns.
B. Telling the daughter to talk with the unit's nurse manager can be an appropriate step, but it should come after gathering information about the situation. The nurse needs to have a clear understanding of what happened before involving the nurse manager.
C. Reassuring the daughter that the mother will get better care may not address her concerns and may not provide a solution to the perceived problem. It is important to gather more information before offering reassurance or making promises.