The unlicensed assistive personnel (UAP) reports to the nurse that a male client with fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the nurse implement?
Ask the client why he does not want to be weighed.
Instruct the UAP to weigh the client using a bed scale
Direct the UAP to delay weighing the client until later.
Document that the client refused daily weights.
None
None
The Correct Answer is A
Choice A Reason: The nurse's first responsibility is to assess the underlying cause of the refusal. Since fluid volume overload is a critical condition, understanding whether the refusal is due to pain, fatigue, or a lack of understanding allows the nurse to provide appropriate education or interventions to ensure compliance with the plan of care.
Choice B Reason: Instructing the UAP to use a bed scale ignores the client's right to refuse and fails to address the initial conflict. Forcing a weight measurement without assessment can damage the nurse-client relationship. The nurse must first determine if the client is physically unable to stand or simply unwilling to participate.
Choice C Reason: Directing the UAP to delay weighing the client until later is not an appropriate action because it may result in missing or inaccurate data. The nurse should ensure that the client is weighed at the same time every day, preferably in the morning, before any fluid intake or output.
Choice D Reason: Documenting that the client refused daily weights is not an adequate action because it does not reflect the nurse's responsibility to provide quality care for the client. The nurse should try to resolve the issue of weighing the client and documenting the outcome and any interventions.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Confronting the nurse manager as a group may not be effective or appropriate, as it may create more conflict and resentment. The charge nurse should follow the chain of command and escalate the issue to a higher authority if the nurse manager fails to act.
Choice B reason: Attending procedures performed by the surgeon and demanding halting of the procedure if the client becomes distressed may be seen as insubordination and interference by the surgeon, who may have legal authority to perform the procedure. It may also jeopardize the client's safety and outcome.
Choice C reason: Documenting client reactions to invasive procedures performed by the physician in their medical record is important, but not sufficient. It does not address the root cause of the problem, which is the surgeon's lack of empathy and respect for clients' pain and dignity.
Choice D reason: Reporting the physician's lack of concern for clients' pain during invasive procedures to the Director of Nursing is the most important action for the charge nurse to take, as it may lead to an investigation and corrective measures. The Director of Nursing has more power and responsibility than the nurse manager to deal with such issues and protect clients' rights and welfare.
Correct Answer is B
Explanation
Choice A Reason: This is not the first priority because it does not address the client's safety and well-being. The charge nurse should inform the pharmacist who dispensed the medication, but this can be done later.
Choice B Reason: This is the best action because it protects the client from harm and prevents further complications. The charge nurse should evaluate the client for symptoms of a drug overdose, such as nausea, vomiting, drowsiness, or respiratory depression, and administer antidotes or supportive measures if needed.
Choice C Reason: This is not the first priority because it does not provide immediate care to the client. The charge nurse should report the medication error to the nursing supervisor, but this can be done later.
Choice D Reason: This is not the first priority because it does not correct the mistake or prevent recurrence. The charge nurse should review the medication transcription with the nurse, but this can be done later.
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