Fundamentals of Nursing: Fluid and Electrolyte Imbalance
Which client is at greatest risk for hypernatremia? A. A 17-year-old with a serum blood glucose of 189 mg/dL B. A 30-year-old on a low-salt diet C. A 42-year-old receiving hypotonic fluids D. A 54-year-old who is sweating profusely
A Excessive sweating is a common cause of hypernatremia. Hyperglycemia, a low-salt diet, and hypotonic fluid administration are common causes of hyponatremia, not hypernatremia.
The nurse is teaching a client who is taking a potassium-sparing diuretic about what foods to avoid. Which foods contain high amounts of potassium? (Select all that apply.) A.Apples B. Bananas C. Broccoli D. Oranges E. Spinach
B,C,D,E Foods high in potassium include bananas, cantaloupe, kiwi, oranges, avocados, broccoli, dried beans, lima beans, mushrooms, potatoes, seaweed, soybeans, and spinach. Apples are considered to be low in potassium.
A client with hyperkalemia is being treated with drugs to improve the condition. Which potassium level indicates that therapy is effective? A. 7.6 mEq/L B. 5.6 mEq/L C. 4.6 mEq/L D. 2.6 mEq/L
C A potassium level of 4.6 mEq/L is a normal level, indicating that therapy was effective. Normal levels are 3.5 to 5.0 mEq/L. A potassium level of 7.6 mEq/L indicates severe hyperkalemia. A potassium level of 5.6 mEq/L indicates hyperkalemia. A potassium level of 2.6 mEq/L indicates hypokalemia.
A client is admitted with hypokalemia and skeletal muscle weakness. Which assessment does the nurse perform first? A. Blood pressure B. Pulse C. Respirations D. Temperature
C Respiratory changes are likely because of weakness of the muscles needed for breathing. Skeletal muscle weakness results in shallow respirations. Thus, respiratory status should be assessed first in any client who might have hypokalemia. Blood pressure and pulse will be altered in this client, but they are not the priority assessment. Temperature is not a priority assessment for the client with hypokalemia.
A client is admitted to the nursing unit with a diagnosis of hypokalemia. Which assessment does the nurse complete first? A. Auscultating bowel sounds B. Checking deep tendon reflexes (DTRs) C. Determining the level of consciousness (LOC) D. Obtaining a pulse oximetry reading
D Because hypokalemia may cause respiratory insufficiency and respiratory arrest, the client's respiratory status should be assessed first. Bowel sounds, DTRs, and LOC may change in a client with hypokalemia, but these changes are not immediately life-threatening.
The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN? A. Calcium level of 9.5 mg/dL B. Magnesium level of 4.1 mEq/L C. Potassium level of 6.0 mEq/L D. Sodium level of 120 mEq/L
A Because a calcium level of 9.5 mg/dL is within normal limits, it is appropriate to assign this client to an LPN/LVN. A magnesium level of 4.1 mEq/L, potassium level of 6.0 mEq/L, and a sodium level of 120 mEq/L are abnormalities in electrolytes that can cause serious complications and will require assessments and/or interventions by the RN.
A 70-year-old woman is admitted to the hospital with heart failure, shortness of breath, and 3+ pitting edema in her lower extremities. Her medications are furosemide (Lasix), digoxin (Lanoxin), and an angiotensin-converting enzyme inhibitor (Lotensin). She states that she stopped taking her Lasix because she did not think that it was helping her heart failure. Her health care provider orders furosemide (Lasix) 5 mg IV push. Ten hours after receiving the Lasix, the client's potassium (K+) level is 2.5 mEq/L. Knowing all of the client's medications, what problem does the nurse anticipate in this client? A. Clinical manifestations of digoxin toxicity B. Increased heart rate and blood pressure (BP) C. Increased signs of congestive heart failure (CHF) D. Signs and symptoms of hypernatremia
A Hypokalemia increases the sensitivity of cardiac muscle to digoxin and may result in digoxin toxicity, even when the digoxin level is within the therapeutic range. Heart rate and BP would be more likely to decrease with the medications that the client is receiving coupled with her low potassium level. Use of a diuretic tends to decrease the signs of CHF. High serum sodium levels would not be expected in this scenario.
A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure. Laboratory results include a potassium level of 7.0 mEq/L. Which medication does the nurse anticipate administering? A. Insulin (regular insulin) and dextrose (D20W) B. Loperamide (Imodium) C. Sodium polystyrene sulfonate (Kayexalate) D. Supplemental potassium
A If potassium levels are high, a combination of 20 units of regular insulin in 100 mL of 20% dextrose in water may be prescribed to promote movement of potassium from the blood into the intracellular fluid. Imodium is used in the treatment of diarrhea. Kayexalate is used for hyperkalemia, but not when the potassium level is this high (7.0). Additional potassium would make the client's condition more critical.
The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? A. Client behavior that changes from anxious and restless to lethargic and confused B. Deep furrows on the surface of the tongue C. Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched D. Urine output of 950 mL for the past 24 hours
A The client's change in level of consciousness from anxious and restless to lethargic and confused suggests poor cerebral blood flow, or shrinkage or swelling of brain cells caused by fluid shifts within the brain cells. These changes indicate a need for immediate intervention to prevent further damage to cerebral function. Deep furrows on the surface of the tongue, poor skin turgor, and low urine output are all caused by the fluid volume deficit, but do not indicate complications of dehydration that are immediately life-threatening.
A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure, and hypertension. His current medications are digoxin (Lanoxin), chlorothiazide (Diuril), and potassium supplements. He tells a nurse that he has had flulike symptoms for the past week and has been unable to drink for the past 48 hours. The nurse starts the client's IV and receives laboratory results, which include a potassium level of 2.7 mEq/L. The physician orders an IV potassium supplement. How does the nurse administer this medication? A. Added to an IV, not to exceed 20 mEq/hr B. Added to an IV, not to exceed 30 mEq/hr C. Rapid IV push, a 25-mEq dose D. Slow IV push, a 30-mEq dose
A The maximum recommended infusion rate of potassium is 5 to 10 mEq/hr. This rate is never to exceed 20 mEq/hr under any circumstances. Potassium should never be administered via IV push.
Which situation can cause a client to experience "insensible water loss"? (Select all that apply.) A. Diarrhea B. Dry, hot weather C. Fever D. Increased respiratory rate E. Nausea F. Mechanical ventilation
A,B,C,D,F Insensible water loss occurs through the intestinal tract as diarrhea. It can be caused and/or influenced by dry, hot weather. Insensible water loss occurs through the skin, and it is increased by the presence of fever. It occurs through the lungs (increased rate of respirations), and is increased in clients who are mechanically ventilated. Nausea with no accompanying vomiting would not cause insensible water loss.
The nurse is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. What does the nurse tell them? A. "Be careful not to overload them with too many oral fluids." B. "Offer fluids that they prefer frequently and on a regular schedule." C. "Restrict their fluids in the evening hours if they are incontinent." D. "Wake them every 2 hours during the night with a drink."
B Because of the decreased thirst mechanism, older adults can become dehydrated and should be offered oral fluids every 2 hours. The likelihood of their accepting the fluid increases if it is one they prefer. Risk of overhydration, especially with oral fluids, is minimal. Fluids should never be restricted because the client is incontinent; this is a common mistake made by UAP in long-term care environments. It is not necessary to disturb older adults during their sleep to offer fluids; however, they should be offered a drink during waking hours at frequent intervals (e.g., every 2 hours).
An older adult client is admitted with dehydration. Which nursing assessment data identify that the client is at risk for falling? A. Dry oral mucous membranes B. Orthostatic blood pressure changes C. Pulse rate of 72 beats/min and bounding D. Serum potassium level of 4.0 mEq/L
B Blood pressure decreases when changing positions. The client may not have sufficient blood flow to the brain, causing sensations of light-headedness and dizziness. This problem increases the risk for falling, especially in older adults. Assessment of oral mucous membranes and the pulse rate can detect symptoms of dehydration, but these are not the best ways to assess for a fall risk. Checking serum potassium does not assess for fall risk.
As adults age, which common physiologic change is likely to alter their hydration status? A. Adrenal gland growth B. Decreased muscle mass C. Increased thirst mechanism D. Poor skin turgor
B Decreased muscle mass causes decreased total body water, thus altering hydration status in the older adult. Adrenal growth is not a common age-related change. A decreased, not increased, thirst reflex is a common change related to aging. Poor skin turgor is a sign, not a cause, of altered hydration status.
A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first? A. Draws blood for laboratory tests B. Elevates the head of the bed C. Places the extremities in a dependent position D. Puts the client in a side-lying position
B Elevating the head of the bed will ease breathing for the client, so it should be done first. Although drawing blood for laboratory tests may be indicated, the nurse should perform interventions that will help with physiologic changes caused by fluid overload first. Placing the extremities in a dependent position increases peripheral edema, and positioning the client in a side-lying position increases the work of breathing.
A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). She is receiving lactated Ringer's solution IV for rehydration. What clinical manifestations does the nurse monitor during rehydration of the client? (Select all that apply.) A. Blood serum glucose B. Blood pressure C. Pulse rate and quality D. Urinary output E. Urine specific gravity levels
B,C,D,E The two most important areas to monitor during rehydration are pulse rate and quality and urine output; however, decreasing specific gravity of urine is also an indication of rehydration. Blood pressure is also important to monitor during rehydration. Blood glucose changes do not have a direct relation to a client's rehydration status.
Which client is at increased risk for fluid and electrolyte imbalance? (Select all that apply.) A. A 22-year-old pregnant woman in her third trimester B. A 24-year-old male athlete C. A 65-year-old man on diuretics D. A 47-year-old man traveling to South America in summer E. A 76-year-old bedridden woman
B,C,E An athlete is at risk for dehydration. An older man on diuretics is at risk for fluid and electrolyte imbalances owing to the action(s) of the drugs. Many of the high-ceiling (loop) diuretics cause loss of potassium as they enable the body to rid itself of excess fluids. Older adults have decreased thirst mechanisms and are at risk for dehydration and subsequent fluid and electrolyte problems. A middle-aged man who is traveling to a hot climate and/or high altitude is at risk for insensible water loss as he acclimates to warmer temperatures. A pregnant client in the third trimester does have an increase in total body fluids, but this accumulation occurs gradually throughout the pregnancy.
A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Her laboratory results include a potassium level of 7.0 mEq/L. What does the nurse include in the client's medication teaching? (Select all that apply.) A. Daily weights are a poor indicator of fluid loss or gain. B. Diuretics can lead to fluid and electrolyte imbalances. C. Diuretics increase fluid retention. D. Laxatives can lead to fluid imbalance. E. It is important to weigh daily at the same time.
B,D,E Diuretics decrease fluid retention and increase loss of fluids, thus can lead to fluid and electrolyte imbalances. Laxatives can also lead to fluid imbalance. Daily weight recording is a good indicator of fluid retention. Clients should be taught to weigh themselves at the same time, in the same clothing, and on the same scale.
A client has a low serum potassium level and is ordered a dose of parenteral potassium chloride (KCl). How does a nurse safely administer KCl to the client? A. Administers 5 mEq intramuscularly B. Dilutes 200 mEq in 1 liter of normal saline and infuses at 100 mL/hr C. Infuses 10 mEq over a 1-hour period D. Pushes 5 mEq through a central access line
C A dose of KCl 10 mEq given over 1 hour is appropriate for this client. A dose of KCl 200 mEq in 1 liter of normal saline infused at 100 mL/hr is too concentrated and can cause injury. Potassium is a severe tissue irritant and is never given by the intramuscular or subcutaneous route. Because rapid infusion of potassium can cause cardiac arrest, potassium is not administered through central lines.
The nurse is reviewing serum electrolytes and blood chemistry for a newly admitted client. Which result causes the greatest concern? A. Glucose: 97 mg/dL B. Magnesium: 2.1 mEq/L C. Potassium: 5.9 mEq/L D. Sodium: 143 mEq/L
C A potassium value of 5.9 mEq/L is high, and the client should be assessed further. A glucose value of 97 mg/dL, a magnesium value of 2.1 mEq/L, and a sodium value of 143 mEq/L are normal values.
The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which client is assigned to the LPN/LVN? A. A 44-year-old with congestive heart failure (CHF) who has gained 3 pounds since the previous day B. A 58-year-old with chronic renal failure (CRF) who has a serum potassium level of 6 mEq/L C. A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L D. An 80-year-old with 3+ peripheral edema and crackles throughout the posterior chest
C Although the 76-year-old client has poor skin turgor, the serum osmolarity indicates that fluid balance is normal; this client is the most stable of the four clients described and can be assigned to the LPN/LVN. The data about the 44-year-old with CHF who has gained 3 pounds since the previous day indicate reduced stability; assessments and interventions performed by an RN are needed. The data about the 58-year-old client with CRF and a serum potassium level of 6 mEq/L indicate reduced stability; assessments and interventions performed by an RN are needed. The data about the 80-year-old client with edema and congested lungs indicate that the client is not stable, and that assessments and interventions by an RN are needed.
The health care provider writes orders for a client who is admitted with a serum potassium level of 6.9 mEq/L. What does the nurse implement first? A. Administer sodium polystyrene sulfonate (Kayexalate) orally. B. Ensure that a potassium-restricted diet is ordered. C. Place the client on a cardiac monitor. D. Teach the client about foods that are high in potassium.
C Because hyperkalemia can lead to life-threatening bradycardia, the initial action should be to place the client on a cardiac monitor. Administering a potassium-reducing medication, recommending a potassium-restricted diet, and teaching the client about diet are appropriate but will not immediately decrease the serum potassium level and do not need to be implemented as quickly as monitoring cardiac rhythm.
The nurse manager of the medical-surgical unit assigns which client to the LPN/LVN? A. A 44-year-old admitted with dehydration who has a heart rate of 126 beats/min B. A 54-year-old just admitted with hyperkalemia who takes a potassium-sparing diuretic at home C. A 64-year-old admitted yesterday with heart failure who still has dependent pedal edema D. A 74-year-old who has just been admitted with severe nausea, vomiting, and diarrhea
C Because the client with heart failure is the most stable of the four clients, this client is most appropriate to assign to the LPN/LVN. Dehydration, tachycardia, potassium overload, and GI signs and symptoms in a client indicate that he or she is unstable and should be cared for by RN staff members.
The nurse is assessing a client with hyponatremia. Which finding requires immediate action? A. Diminished bowel sounds B. Heightened acuity C. Muscular weakness D. Urine output of 35 mL/hr
C Muscle weakness in clients with hyponatremia requires immediate action. If muscle weakness is present, immediately check respiratory effectiveness because ventilation is dependent on adequate strength of the respiratory muscles. Excessive bowel sounds, not diminished bowel sounds, are expected in the client with hyponatremia, as well as mild confusion, not heightened acuity. A urine output of 35 mL/hr is normal (minimally) and does not require immediate action.
The nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical? A. Monitoring 24-hour urine output B. Asking the client about feeling depressed C. Hourly deep tendon reflexes (DTRs) D. Monitoring of serum calcium levels
C The client who is receiving IV magnesium sulfate should be assessed for signs of toxicity every hour by assessment of DTRs. Most clients who have fluid and electrolyte problems will be monitored for intake and output; this will not immediately generate data about problems with magnesium overdose. Low magnesium levels can cause psychological depression, but assessing this parameter as the levels are restored would not be a method by which to safely assess a safe dose or an overdose. Although administration of magnesium sulfate can cause a drop in calcium levels, this occurs over a period of time and would not be the best way to assess magnesium toxicity.
After receiving change-of-shift report, which client does the RN assess first? A. A 26-year-old with nausea and vomiting who complains of dizziness when standing B. A 36-year-old with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst C. A 46-year-old receiving intravenous (IV) diuretics whose blood pressure is 95/52 mm Hg D. A 56-year-old with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL
C The client with the history of receiving IV diuretics and having low blood pressure may be experiencing hypoperfusion caused by hypovolemia, and immediate assessment and interventions are needed. The client with nausea and vomiting, the client with an NG tube complaining of thirst, and the client receiving normal saline with an hourly urine output of 75 mL/hr have problems that are not urgent at this time.
The client is a 69-year-old woman with uncontrolled diabetes, polyuria, and a blood pressure of 86/46 mm Hg. Which staff member is assigned to care for her? A. LPN/LVN who has floated from the hospital's long-term care unit B. LPN/LVN who frequently administers medications to multiple clients C. RN who has floated from the intensive care unit D. RN who usually works as a diabetes educator
C The clinical manifestations suggest that the client is experiencing hypovolemia and possible hypovolemic shock. The RN who floated from the intensive care unit will have extensive experience caring for clients with hypovolemia. The LPN/LVN who has floated from the long-term care unit or who frequently administers medications to multiple clients will not be as familiar with care for critically ill clients. The LPN/LVN is not qualified to care for a client with these complications. Although the resource on diabetes is helpful, the RN who works as a diabetes educator will not be as familiar with care for critically ill clients.
A 70-year-old woman is admitted to the hospital with heart failure, shortness of breath, and 3+ pitting edema in her lower extremities. Her current medications are furosemide (Lasix), digoxin (Lanoxin), and an angiotensin-converting enzyme inhibitor (Lotensin). She states that she stopped taking her Lasix because she did not think that it was helping her heart failure. Her health care provider orders furosemide (Lasix) 5 mg IV push. Which client assessment determines that the medication is working? A. Decreased blood pressure (BP) B. Increased heart rate C. Increased urine output D. Weight gain
C When giving Lasix, the nurse monitors the client for response to drug therapy, especially weight loss and increased urine output. Although a fall in the client's BP may occur with the decrease in body fluid, this is not the most important assessment to be monitored. Urinary output is most important. Lasix may cause a decrease in heart rate as it lowers the client's body fluid, but this effect would take some time to note. Weight loss, rather than weight gain, is often the effect of Lasix, but it does not occur immediately.
A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His current medications are digoxin (Lanoxin), chlorothiazide (Diuril), and oral potassium supplements. He tells the nurse that he has had flulike symptoms for the past week and has been unable to drink for the past 48 hours. The health care provider requests laboratory specimens to be drawn and an isotonic IV to be started. Which IV fluid does the nurse administer? A. 0.45% saline B. 5% dextrose in 0.45% saline C. 5% dextrose in Ringer's lactate D. 5% dextrose in water (D5W)
D 5% dextrose in water (D5W) is an isotonic solution. 0.45% saline is a hypotonic solution, while 5% dextrose in 0.45% saline and 5% dextrose in Ringer's lactate are hypertonic solutions.
A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide? A. Assessment of muscle tone and strength B. Education about potassium-rich foods C. Instruction on the proper use of drugs D. Measurement of the client's urine output
D A home health aide may measure the client's intake and output, which then would be reported to the RN. Assessment, education, and instruction are higher-level nursing actions that should be done by the RN.
A 90-year-old client with hypermagnesemia is seen in the emergency department (ED). The ED nurse prepares the client for admission to which inpatient unit? A. Dialysis/home care B. Geriatric/rehabilitation C. Medical-surgical D. Telemetry/cardiac stepdown
D Because hypermagnesemia causes changes in the cardiac rhythm that may result in cardiac arrest, the client should be admitted to the telemetry/cardiac stepdown unit. Dialysis/home care units, geriatric/rehabilitation units, and medical-surgical units typically do not have cardiac monitoring capabilities.
Which newly written prescription does the nurse administer first? A. Intravenous normal saline to a client with a serum sodium of 132 mEq/L B. Oral calcium supplements to a client with severe osteoporosis C. Oral phosphorus supplements to a client with acute hypophosphatemia D. Oral potassium chloride to a client whose serum potassium is 3 mEq/L
D Because minor changes in serum potassium level can cause life-threatening dysrhythmias, the first priority should be to administer potassium supplements to the client with hypokalemia. The electrolyte disturbances (sodium level of 132 and low phosphorus level) and the need for calcium in the other clients are not immediately life-threatening.
A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure. Her laboratory results include a potassium level of 7.0 mEq/L. What is the primary goal of drug therapy for this client? A. Decreasing cardiac contractility and slowing the heart rate B. Elevating serum potassium levels to a safe range C. Maintaining proper diuresis and urine output D. Restoring fluid balance by controlling the causes of dehydration
D Drug therapy for dehydration is directed at restoring fluid balance and controlling the causes of dehydration. Hyperkalemia (serum potassium level of 7.0) will slow the cardiac rate and cause decreased contractility of the heart. Serum potassium levels are already critically high, so should not be elevated further. Excessive diuretic use is what has caused this client's problems. What she needs now is to have electrolyte balance restored; for potassium, that is 3.5 to 5.0 mEq/L.
The nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)? A. Assessing oral mucosa for dryness B. Choosing appropriate oral fluids C. Monitoring skin turgor for tenting D. Offering fluids to drink every hour
D Encouraging a client to take oral fluids is within the scope of practice for UAP. Assessments of oral mucosa, selection of appropriate fluids, and assessment of skin turgor should be done by licensed nursing staff, who have the needed education and scope of practice to implement these more complex actions.
The nurse is instructing a client who is being discharged with a diagnosis of congestive heart failure (CHF). Which client statement indicates a correct understanding of CHF? A. "I can gain 2 pounds of water a day without risk." B. "I should call my provider if I gain more than 1 pound a week." C. "Weighing myself daily can determine if my caloric intake is adequate." D. "Weighing myself daily can reveal increased fluid retention."
D Fluid retention may not be visible. Rapid weight gain is the best indicator of fluid retention and overload. Each pound of weight gained (after the first half-pound) equates to 500 mL of retained water. The client should be weighed at the same time every day (before breakfast) on the same scale. The client should call the health care provider if more than 1 or 2 pounds are gained in a 24-hour period or if more than 3 pounds are gained in 1 week. Daily weights are not an indication of effective dieting for purposes of weight loss or gain. They will show fluid retention after an especially high sodium intake (in a client with fluid retention problems), but caloric intake is related to food intake rather than fluid retention problems.
The RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to unlicensed assistive personnel (UAP)? A. Consulting with a health care provider about a client's laboratory results B. Infusing 500 mL of normal saline over 60 minutes C. Monitoring IV fluid to maintain the drip rate at 75 mL/hr D. Providing oral care every 1 to 2 hours
D Frequent oral care is an important intervention for a client with fluid volume deficit and is appropriate to delegate to UAP. Consulting with a health care provider about a client's laboratory results, infusing 500 mL of normal saline, and monitoring IV fluid are complex actions and should be accomplished by licensed personnel.
The nurse instructs an older adult client to increase intake of dietary potassium when the client is prescribed which classification of drugs? A. Alpha antagonists B. Beta blockers C. Corticosteroids D. High-ceiling (loop) diuretics
D High-ceiling (loop) diuretics are potassium-depleting drugs. The client should increase intake of dietary potassium to compensate for this depletion. Alpha antagonists, beta blockers, and corticosteroids are not potassium-depleting drugs.
A client is being monitored for daily weights. The night nurse asks the nursing assistant for the morning weight, and the assistant replies, "She was sleeping so well, I didn't want to wake her to get her weight." How does the nurse respond? A. "Fast thinking! She really needs to rest after the night she had." B. "Get the information now, or I'll report you for not doing your job." C. "Never mind—I will do it myself." D. "Weigh her now. We need her weight daily, at the same time."
D The nurse should educate the nursing assistant as to why obtaining the client's weight at the same time each day is important. Although the nursing assistant may be hesitant to wake the client, assessing the client's fluid balance is more important. The responses that the client needed the rest, telling the nursing assistant to get the information now or she'll be reported, or that the nurse will get the information herself do not demonstrate good leadership. The assistant needs to understand the rationale for waking and weighing the client. She should not be dismissed and belittled by the nurse.
The nurse is planning care for a client with hypocalcemia. Which nursing action is appropriate to delegate to unlicensed assistive personnel (UAP)? A. Collaborating with the dietitian to provide calcium-rich foods for the client B. Evaluating the client's laboratory results C. Implementing seizure precautions for the client D. Transferring the client from the bed to a stretcher using a lift sheet
D Transferring clients is a nursing skill that is included in UAP education and scope of practice. Collaborating with the dietitian, evaluating the client's laboratory results, and implementing seizure precautions all require broader education and scope of practice and should be done by licensed nursing personnel.
The RN is caring for a client admitted with dehydration who requires a blood transfusion. Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)? A. Inserting a small-gauge needle for intravenous (IV) access B. Evaluating a headache that develops during the transfusion C. Explaining to the client the purpose of the blood transfusion D. Obtaining baseline vital signs before blood administration
D UAP education includes assessment of vital signs, so obtaining vital signs is within their scope of practice. IV starts, evaluating client symptoms, and explaining the purpose of a blood transfusion require broader education and scope of practice and should be done by licensed staff members.
