The unlicensed assistive personnel (UAP) reports to the practical nurse (PN) that a male clientwith fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the PN implement?
Include "Noncompliance”. as a priority problem in the client's plan of care.
Advise the UAP to re-attempt the daily weight after the client eats breakfast.
Consult with the client about the reasons for his refusal to be weighed
Calculate the client's weight based on the 24-hour fluid intake and output.
The Correct Answer is C
The correct answer is choice C. Consult with the client about the reasons for his refusal to be weighed.
Choice A rationale:
Including "Noncompliance”. as a priority problem in the client's plan of care assumes the client's refusal to be weighed is intentional and willfully disobedient. This may not be the case, and labeling the client as noncompliant could create a negative atmosphere, hindering effective communication and care.
Choice B rationale:
Advising the UAP to re-attempt the daily weight after the client eats breakfast does not address the underlying reason for the client's refusal. Additionally, there is no evidence suggesting that weighing the client after breakfast will improve the situation.
Choice C rationale:
Consulting with the client about the reasons for his refusal to be weighed is the most appropriate action. Open communication with the client can help identify any concerns or fears related to the weighing process. By understanding the client's perspective, the healthcare team can work together to find a solution that ensures the client's cooperation with the weight monitoring.
Choice D rationale:
Calculating the client's weight based on the 24-hour fluid intake and output is not a reliable method for obtaining an accurate weight measurement. Fluid volume overload can lead to fluid retention and may not accurately reflect the client's true weight.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale:
Obtaining a post-voided residual (PVR) volume is a non-invasive procedure that can be safely delegated to the unlicensed assistive personnel (UAP) to measure the amount of urine left in the bladder after urination.
Choice B rationale:
Teaching the client with fluid restrictions how to measure urine output requires specialized knowledge and is best performed by the practical nurse (PN).
Choice C rationale:
Emptying the bedside drainage unit for a client with an indwelling urinary catheter is a task that can be delegated to the UAP as it involves routine drainage and does not require advanced nursing skills.
Choice D rationale:
Irrigating an indwelling urinary catheter for a client with bladder suspension is a sterile procedure that requires nursing expertise, so it should not be assigned to the unlicensed assistive personnel.
Choice E rationale:
Transporting a urine culture sample to the laboratory is a non-complex task that can be safely delegated to the UAP to ensure timely and efficient delivery.
Correct Answer is D
Explanation
Observe the UAP's technique and communication skills during the bath.
The PN should directly observe the UAP's performance and provide feedback and guidance as needed. This can help ensure that the UAP follows the standards of care and respects the client's dignity and preferences.
The other options are not correct because:
- Asking another UAP to help the orientee may not be appropriate or necessary, as it may interfere with the orientation process and create confusion or conflict.
- Verifying with the client that the bath was complete and thorough may not be sufficient or reliable, as the client may not be able to assess the quality of care or may not want to complain.
- Inspecting the client's skin near the end of the bathing procedure may not be timely or comprehensive, as it may miss some aspects of care or some problems that occurred during the bath.
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