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This response focuses on the nurse’s ability rather than appropriate delegation. Delegating tasks helps manage time and resources effectively when delegation is safe and appropriate.

Weighing clients does not require nursing judgment; it is a routine, stable task that is appropriate for delegation under the right conditions.

Weights obtained on new clients may be needed before a full nursing assessment, but initial assessments must be performed by a nurse, not delegated to APs.

Atrial fibrillation: Atrial fibrillation is characterized by an irregularly irregular rhythm and the absence of identifiable P waves. It does not present with a consistent PR interval, making this an incorrect match for the findings.

Complete heart block: In third-degree or complete heart block, there is no relationship between P waves and QRS complexes—the atria and ventricles beat independently. The PR interval varies and is not constant.

Premature atrial complexes: These are early beats originating from the atria, often with a shortened or normal PR interval and an abnormal P wave. A consistently prolonged PR interval is not characteristic of PACs.

Trim the fat from red meat prior to cooking: Children with cystic fibrosis often require higher fat intake due to malabsorption, so removing fat is not recommended unless medically indicated for another reason.

Give the child hot foods to reduce the sense of fullness: There is no physiological basis to suggest that giving hot foods reduces a sense of fullness in children with cystic fibrosis. Large volumes or very hot/cold foods could potentially exacerbate gastrointestinal discomfort. fullness is more effectively managed with enzyme support and meal planning.

Administer pancreatic enzymes 30 min after meals: Pancreatic enzymes should be given just before or at the start of meals to aid digestion effectively. Giving them 30 minutes after eating would not support optimal nutrient absorption.

Coarse lung sounds: These are indicative of secretions in the larger airways and may suggest fluid overload or pulmonary complications but are not specific to cardiac tamponade and are considered a later or unrelated finding in this context.

Decreased jugular vein distention: Accumulation of fluid in the pericardial sac compresses the heart and impairs its ability to fill typically causing increased jugular venous pressure, so a decrease would not be expected and does not indicate early tamponade.

Widening pulse pressure: Narrowing, not widening, of the pulse pressure is more characteristic of cardiac tamponade due to decreased stroke volume and rising intrapericardial pressure.

Critical pathways have an unlimited timeframe for completion: Critical pathways are designed with specific timelines to standardize care and ensure timely achievement of outcomes, so they do not have unlimited timeframes.

Nurses should discontinue the critical pathway if variances occur: Variances are documented and addressed, not a reason to discontinue the pathway. They help track deviations and guide individualized care adjustments.

Nurses' notes are used to create the critical pathway: Critical pathways are developed from evidence-based guidelines and clinical expertise, not directly from nurses' notes, though documentation helps evaluate their effectiveness.

"Eat foods that are high in sodium.": Sodium intake should be limited in clients with heart failure, as high sodium can worsen fluid retention and counteract the effects of diuretics like furosemide.

“Taking furosemide can cause you to be overhydrated.": Furosemide increases urine output and poses a risk of dehydration, not overhydration. Monitoring fluid balance is essential during treatment.

"Taking furosemide can cause your potassium levels to be high.": Furosemide can lead to hypokalemia (low potassium), not hyperkalemia. Clients may need potassium supplementation or dietary adjustments to prevent electrolyte imbalance.

Email the client's health information to the facility in an unencrypted file: Sending unencrypted files by email is a breach of confidentiality and violates HIPAA regulations. Protected health information must be securely transmitted.

Discuss the client's response to the transfer with another staff nurse: Unless the staff nurse is directly involved in the client’s care, this discussion would be inappropriate and a violation of the client’s privacy.

Fax the client's name and identifiable information to the rehabilitation facility: Faxing may be permitted if secured, but the question implies sending identifiable information without confirming secure transmission. This could risk unauthorized disclosure.

Bowel movement 5 days ago: Constipation is a common side effect of morphine and should be addressed, but it is not immediately life-threatening and can be managed with laxatives or stool softeners.

Pupil diameter 6 mm: Pupil dilation is not a typical concern with morphine; miosis (constriction) is more commonly expected. While abnormal pupil size can indicate neurologic or drug-related issues, hypotension takes priority here.

Urinary output 120 mL/4 hr: This output equals 30 mL/hr, which is within the expected minimum range. No immediate intervention is required, though continued monitoring is appropriate.

Cleanse the insertion site of the drain using a circular motion toward the center: Wound cleansing should proceed from the center outward, not toward the center, to avoid introducing contaminants into the wound or insertion site.

Cleanse the wound starting at the bottom and moving upward: Wound cleansing should always be done from the cleanest to dirtiest area starting at the top (incision site) and moving downward, not the reverse, to prevent contamination.

Irrigate the wound using a 10 mL syringe: A 10 mL syringe does not generate sufficient volume or pressure for effective wound irrigation. Larger syringes (30–60 mL) are preferred to provide adequate flow for proper cleansing.

Remove the peripheral IV site: The IV site should be maintained with normal saline to keep access open for potential emergency medications or further treatment. Removing it too early may hinder urgent intervention.

Infuse 0.9% sodium chloride through the infusion set tubing: Normal saline should be infused after stopping the transfusion, but it must be done through new tubing to avoid continued exposure to the blood product.

Monitor the client's vital signs every 30 min: While vital sign monitoring is important, it is not the first or most urgent action. The priority is to stop the transfusion and address the reaction promptly.

A 25-gauge needle: This needle is too small and inappropriate for accessing a venous access port. It also risks damaging the port septum and does not allow for adequate flow during infusions.

A butterfly needle: Butterfly needles are intended for short-term peripheral venous access and are not designed for port access. Using one could damage the port or increase infection risk.

An angiocatheter: Angiocatheters are used for peripheral IV access, not for implanted ports. They do not have the correct tip design to safely access the septum of a port without causing damage.

Warm the irrigation solution: While warming may enhance comfort, it does not impact the color of urine or address post-procedure bleeding. It is not a necessary intervention in this situation.

Perform the Credé's maneuver: This technique, which involves manual pressure over the bladder, is used for clients with neurogenic bladder or urinary retention. It is not appropriate during continuous bladder irrigation.

Replace the indwelling urinary catheter: Catheter replacement would only be considered if there was a complete blockage that couldn't be cleared, severe kinking, or signs of infection, none of which are indicated here. Replacing the catheter unnecessarily increases the risk of trauma and infection.

Have protamine sulfate available at the bedside: Protamine sulfate is an antidote for heparin, not epidural anesthesia. It has no role in managing side effects or complications related to an epidural.

Monitor the client for hypertension: Epidural anesthesia commonly causes hypotension due to vasodilation. The nurse should monitor for low blood pressure, not elevated readings.

Decrease the maintenance infusion rate of IV fluid: IV fluids are often increased prior to and after epidural placement to counteract potential hypotension. Reducing the rate could worsen the risk of low blood pressure.

Wear clothing with zippers instead of buttons: While simplifying clothing is helpful, Velcro or elastic waistbands are typically easier for clients with cognitive decline than zippers, which can still be difficult to manage.

Encourage physical activity prior to bedtime: Physical activity should be scheduled earlier in the day. Stimulating activity near bedtime may worsen sleep disturbances or contribute to sundowning in clients with Alzheimer’s disease.

Replace the carpet with hardwood floors: Removing carpet can increase the risk of slipping and falling. Soft flooring like carpet may actually provide better traction and cushion in the event of a fall.

Sit next to the client when speaking to them: Sitting in front of the client is more effective, as it allows the client to see the nurse’s facial expressions and lip movements, which can aid comprehension.

Lower the tone of voice at the end of each sentence: Lowering tone may make speech harder to hear. Many people with hearing loss have difficulty hearing low-pitched sounds, so lowering the tone can reduce clarity.

Emphasize vowel sounds when speaking: Vowel sounds are softer and less distinct than consonants. Emphasizing consonants and speaking clearly at a moderate pace is more effective than focusing on vowels.

Hydrocodone: This opioid is typically used for moderate pain and may not provide sufficient relief for pain rated as 7 out of 10. It would be considered if the pain were less severe.

Aspirin: As a non-opioid analgesic, aspirin is suitable for mild to moderate pain and has anti-inflammatory effects. It would be inadequate for managing severe pain from a fractured leg.

Acetaminophen: Appropriate for mild to moderate pain, acetaminophen lacks the potency needed for severe pain and does not have anti-inflammatory properties to aid in tissue trauma like a fracture.