A client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a nursing assistant?
- A. Administer IV fluids as prescribed by the physician.
- B. Provide straws and offer fluids between meals.
- C. Develop plan for added fluid intake over 24 hours.
- D. Teach family members to assist client with fluid intake.
Correct Answer: B
Rationale: The nursing assistant can effectively encourage oral fluid intake by offering fluids between meals, which is within their scope of practice. Administering IV fluids, developing plans, and teaching family members are more advanced tasks that require higher-level nursing skills.
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What is the primary role of lubricating eye drops?
- A. Moisten the eyes
- B. Treat infections
- C. Correct refractive errors
- D. None of the above
Correct Answer: A
Rationale: Lubricating drops relieve dryness and discomfort by moisturizing the ocular surface.
When developing a teaching plan for a patient, what should the nurse recognize?
- A. Frustration will enhance the patient’s desire to learn
- B. Only formal teaching plans have been found to be effective
- C. The patient’s previous educational experiences do not influence his learning
- D. The patient must accept responsibility for compliance with his therapeutic regimen
Correct Answer: D
Rationale: Patient responsibility is essential for adherence to therapeutic regimens.
The most important laboratory value to monitor in a patient with heavy bleeding due to fibroids is:
- A. Hemoglobin
- B. Luteinizing hormone
- C. White blood cell count
- D. Potassium
Correct Answer: A
Rationale: Hemoglobin levels are critical to assess the severity of blood loss and anemia in patients with heavy bleeding.
How can a nurse foster effective coping skills?
- A. Deep breathing exercises
- B. Avoid social interactions
- C. Ignore stressors
- D. Increase workload
Correct Answer: B
Rationale: The correct answer is B because it is the most appropriate response based on physiological and medical principles.
What changes are seen in the skin during shock?
- A. Increased urine output
- B. Edema
- C. Hypertension
- D. Hypernatremia
Correct Answer: B
Rationale: Edema occurs due to excess fluid accumulation in the interstitial spaces, commonly seen in conditions like heart failure and kidney disease.