PRIORITIZATION DELEGATION AND
ASSIGNMENT 4TH EDITION LACHARITY
TEST BANK 9780323498289 Practice
Exercises for the NCLEX Examination (With A
New Update) 2024.pdf
The nurse is caring for a client who experiences frequent generalized tonic-clonic
seizures associated with periods of apnea. The nurse must be alert for which acid-base
imbalance?
•Respiratory alkalosis
•Respiratory acidosis
•Metabolic alkalosis
•Metabolic acidosis - ANSWERS--•Metabolic acidosis
The RN is admitting a client with benign prostatic hyperplasia (BPH) to an acute care
unit. The client describes an oral intake of about 1400 mL/day. What is the RN's
*priority* concern?
•Ask the client about his or her bowel movements
•Have the client complete a diet diary for the past 2 days
•Instruct the client to increase oral intake to 2 to 3 L/day
•Ask the client to describe his urine output - ANSWERS--•Instruct the client to increase
oral intake to 2 to 3 L/day
, •An adult should take in about 2 to 3 L of fluid daily from food and liquids. Although the
RN would want to know about bowel movements, dietary intake, and urine output, in
this case, the priority is that the client is not taking in enough oral fluids.
•UAPs can reinforce additional fluid intake when 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.
The unlicensed assistive personnel (UAP) reports to the nurse that a client's urine
output for the past 24 hours has been only 360 mL. What is the nurse's *priority* action
at this time?
•Place an 18-gauge IV in the nondominant arm
•Elevate the client's head of bed at least 45 degrees
•Instruct the UAP to provide the client with a pitcher of ice water
•Contact and notify the health care provider immediately - ANSWERS--•Contact and
notify the health care provider immediately
•The minimum amount of urine per day needed to excrete toxic waste products is 400 to
600 mL. This minimum volume is called the obligatory urine output. If the 24-hour urine
output falls below the obligatory output amount, wastes are retained and can cause
lethal electrolyte imbalances, acidosis, and a toxic buildup of nitrogen. The client may
need additional fluids (IV or oral) after the cause of the low urine output is determined.
Elevating the head of the bed will not help with urine output. Notifying the health care
provider is the first priority in this case.
The client described in question 3 is also at risk for poor perfusion related to decreased
plasma volume. Which assessment finding supports this risk?
•Flattened neck veins when the client is in the supine position
•Full and bounding pedal and post-tibial pulses
•Pitting edema located in the feet, ankles, and calves
•Shallow respirations with crackles on auscultation - ANSWERS--•Flattened neck veins
when the client is in the supine position
The client has fluid volume deficit related to excessive fluid loss. Which action related to
fluid management should be delegated by the RN to unlicensed assistive personnel
(UAP)?
•Administering IV fluids as prescribed by the physician
•Providing straws and offering fluids between meals
•Developing a plan for added fluid intake over 24 hours
•Teaching family members to assist the client with fluid intake - ANSWERS--•Providing
straws and offering fluids between meals
ASSIGNMENT 4TH EDITION LACHARITY
TEST BANK 9780323498289 Practice
Exercises for the NCLEX Examination (With A
New Update) 2024.pdf
The nurse is caring for a client who experiences frequent generalized tonic-clonic
seizures associated with periods of apnea. The nurse must be alert for which acid-base
imbalance?
•Respiratory alkalosis
•Respiratory acidosis
•Metabolic alkalosis
•Metabolic acidosis - ANSWERS--•Metabolic acidosis
The RN is admitting a client with benign prostatic hyperplasia (BPH) to an acute care
unit. The client describes an oral intake of about 1400 mL/day. What is the RN's
*priority* concern?
•Ask the client about his or her bowel movements
•Have the client complete a diet diary for the past 2 days
•Instruct the client to increase oral intake to 2 to 3 L/day
•Ask the client to describe his urine output - ANSWERS--•Instruct the client to increase
oral intake to 2 to 3 L/day
, •An adult should take in about 2 to 3 L of fluid daily from food and liquids. Although the
RN would want to know about bowel movements, dietary intake, and urine output, in
this case, the priority is that the client is not taking in enough oral fluids.
•UAPs can reinforce additional fluid intake when 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.
The unlicensed assistive personnel (UAP) reports to the nurse that a client's urine
output for the past 24 hours has been only 360 mL. What is the nurse's *priority* action
at this time?
•Place an 18-gauge IV in the nondominant arm
•Elevate the client's head of bed at least 45 degrees
•Instruct the UAP to provide the client with a pitcher of ice water
•Contact and notify the health care provider immediately - ANSWERS--•Contact and
notify the health care provider immediately
•The minimum amount of urine per day needed to excrete toxic waste products is 400 to
600 mL. This minimum volume is called the obligatory urine output. If the 24-hour urine
output falls below the obligatory output amount, wastes are retained and can cause
lethal electrolyte imbalances, acidosis, and a toxic buildup of nitrogen. The client may
need additional fluids (IV or oral) after the cause of the low urine output is determined.
Elevating the head of the bed will not help with urine output. Notifying the health care
provider is the first priority in this case.
The client described in question 3 is also at risk for poor perfusion related to decreased
plasma volume. Which assessment finding supports this risk?
•Flattened neck veins when the client is in the supine position
•Full and bounding pedal and post-tibial pulses
•Pitting edema located in the feet, ankles, and calves
•Shallow respirations with crackles on auscultation - ANSWERS--•Flattened neck veins
when the client is in the supine position
The client has fluid volume deficit related to excessive fluid loss. Which action related to
fluid management should be delegated by the RN to unlicensed assistive personnel
(UAP)?
•Administering IV fluids as prescribed by the physician
•Providing straws and offering fluids between meals
•Developing a plan for added fluid intake over 24 hours
•Teaching family members to assist the client with fluid intake - ANSWERS--•Providing
straws and offering fluids between meals
