Prioritization, Delegation, Assignmentimmunological Problems Chp4 100% Q&A Verified Solution 2023

1. The client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a UAP? 1. Administering IV fluids as prescribed by the physician 2. Providing straws and offering fluids between meals 3. Developing a plan for added fluid intake over 24 hours 4. Teaching family members to assist the client with fluid intake - 1. Ans: 2. Providing straws and offering fluids between meals UAPs can reinforce additional fluid intake once it is part of the care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice of an RN. Focus: Delegation, supervision 2. The client also has the nursing diagnosis Decreased Cardiac Output related to decreased plasma volume. Which assessment finding supports this nursing diagnosis? 1. Flattened neck veins when the client is in the supine position 2. Full and bounding pedal and post-tibial pulses 3. Pitting edema located in the feet, ankles, and calves 4. Shallow respirations with crackles on auscultation - 2. Ans: 1. Flattened neck veins when the client is in the supine position . Providing straws and offering fluids between meals Normally, neck veins are distended when the client is in the supine position. These veins flatten as the client moves to a sitting position. The other three responses are characteristic of the nursing diagnosis of Excess Fluid Volume. Focus: Prioritization 3. The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? (Select all that apply.) 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 3. Observing the lips, tongue, and mucous membranes 4. Providing mouth care every 2 hours while the client is awake 5. Seeking a dietary consult to increase fluids on meal trays - 3. Ans: 1, 2, 3, 4 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 3. Observing the lips, tongue, and mucous membranes 4. Providing mouth care every 2 hours while the client is awake The LPN/LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPNs/LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes, which contain alcohol, a drying agent. Initiating a dietary consult is within the purview of the RN or physician. Focus: Delegation, supervision 4. The health care provider has written all of these orders for a client with a diagnosis of Excess Fluid Volume. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? 1. Weigh the client every morning. 2. Maintain accurate intake and output records. 3. Restrict fluids to 1500 mL/day. 4. Administer furosemide (Lasix) 40 mg IV push. - 4. Ans: 4. Administer furosemide (Lasix) 40 mg IV push. Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. The other orders are important, but are not urgent. Focus: Prioritization 5. You have been floated to the telemetry unit for the day. The monitor watcher informs you that the client has developed prominent U waves. Which laboratory value should you check immediately? 1. Sodium 2. Potassium 3. Magnesium 4. Calcium - 5. Ans: 2. Potassium Suspect hypokalemia and check the client's potassium level. Common ECG changes with hypokalemia include ST-segment depression, inverted T waves, and prominent U waves. Clients with hypokalemia may also develop heart block. Focus: Prioritization 6. A client's potassium level is 6.7 mEq/L. Which intervention should you delegate to the first-year student nurse whom you are supervising? 1. Administer sodium polystyrene sulfonate (Kayexalate) 15 g orally. 2. Administer spironolactone (Aldactone) 25 mg orally. 3. Assess the electrocardiogram (ECG) strip for tall T waves. 4. Administer potassium 10 mEq orally. - 6. Ans: 1. Administer sodium polystyrene sulfonate (Kayexalate) 15 g orally. CONTINUES...