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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Instruct the UAP to lower the bed for safety.

This is the best action for the PN to take because it ensures the client's safety and prevents potential falls or injuries. The PN should also educate the UAP on the importance of lowering the bed when providing care to a bedfast client.

A. Assuming care of the client immediately is not necessary and may undermine the UAP's confidence and competence.

B. Remaining in the room to supervise the UAP is not appropriate and may interfere with the client's privacy and dignity.

D. Determining if the UAP would like assistance is not a priority and may not address the safety issue.

A. States the importance of maintaining current immunization schedule. B. Wears a mask each time when leaving the room. C. Demonstrates disposal of personal tissues in no-touch receptacle. D. Explains importance of wearing protective clothing when outdoors.

Correct Answer is D

Explanation

The correct answer is choiced. Explains importance of wearing protective clothing when outdoors.

Choice A rationale:

Maintaining a current immunization schedule is important for overall health, but it is not directly related to Lyme disease prevention or management, as there is no vaccine for Lyme disease in humans.

Choice B rationale:

Wearing a mask when leaving the room is a precaution for airborne diseases, not for Lyme disease, which is transmitted through tick bites.

Choice C rationale:

Disposal of personal tissues in a no-touch receptacle is a general infection control measure but does not specifically address Lyme disease prevention or management.

Choice D rationale:

Wearing protective clothing when outdoors is crucial for preventing tick bites, which are the primary mode of transmission for Lyme disease. This measure directly addresses the prevention of Lyme disease.

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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?

Nursing Test Bank

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Correct Answer is D

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