Prioritization, delegation, assignment: CH 4 Fluid/Electrolyte/Acid-Base

The client has a nursing diagnosis of Deficient Fluid Volume related to excessive fluid loss *AND* Decreased Cardiac Output related to decreased plasma volume. Which assessment finding supports this nursing diagnosis? 1. Flattened neck veins when client is in supine position 2. Full and bounding pedal and post-tibial pulses 3. Pitting edema @ feet, ankles, calves 4. Shallow respirations w/crackles on auscultation

1. Flattened neck veins when client is in supine position

The nursing care plan for a 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? (SATA) 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 3. Observing the lips, tongue, mucous membranes 4. Providing mouth care every 2 hours while the client is awake 5. Seeking dietary consult to increase fluids on meal trays

1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 3. Observing the lips, tongue, mucous membranes 4. Providing mouth care every 2 hours while the client is awake *initiating a dietary consult is within the purview of the RN or physician*

A client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action to the 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

2. Providing straws and offering fluids between meals UAPs can reinforce fluid intake once it is part of the care plan.

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) 2. Administer spironolactone 3. Assess the ECG strip for tall T waves 4. Administer potassium

3. Assess the ECG strip for tall T waves

The UAP asks you why the client with a chronically low phosphorus level needs so much assistance with ADLs. What is your best response? 1. Client's low phosphorus is probably due to malnutrition 2. Client is worn out from not getting enough rest 3. Client's skeletal muscles are weak because of low phosphorus 4. The client will do more for himself when his phosphorus level is normal

3. Client's skeletal muscles are weak because of low phosphorus

The HCP has written all of the following orders for a client with a diagnosis of Excess Fluid Volume. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2lbs, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? 1. weigh the client every morning 2. Maintain accurate Is & Os 3. Restrict fluids to 1500 mL/day 4. Administer furosemide 40 mg IV push

4. Administer furosemide 40 mg IV push

You are preparing to discharge a client whose calcium level was low but is now barely within normal range. Which statement by the client indicates to you the need for additional teaching? 1. "I will call my doctor if I experience muscle twitching or seizures." 2. I will make sure to take my vitamin D with my calcium each day. 3. I will take my calcium citrate pill every morning before breakfast. 4. I will avoid dairy products, broccoli, and spinach when I eat.

4. I will avoid dairy products, broccoli, and spinach when I eat.