Nokea
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.
You may also like to solve these questions
Bob is diagnosed with idiopathic thrombocytopenic purpura (ITP). You realize that he has an increased risk of bleeding and you must monitor
- A. WBC and bleeding time.
- B. Prothrombin time (PT) and partial thromboplastin time (PTT).
- C. Platelet count and RBC.
- D. Iron and ferritin levels.
Correct Answer: C
Rationale: Low platelet count increases the risk of bleeding in ITP.
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.
A client with chronic obstructive pulmonary disease (COPD tells the nurse, 'I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up.' Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?
- A. Maintaining a semi-Fowler's position as often as possible
- B. Administering oxygen via nasal cannula at 2 L/min
- C. Helping the client select a low-salt diet
- D. Encouraging the client to drink 2 to 3 L of water daily
Correct Answer: D
Rationale: The correct answer is D: Encouraging the client to drink 2 to 3 L of water daily. Increased fluid intake helps to thin out bronchial secretions, making them easier to cough up. Step-by-step rationale:
1. Increased water intake promotes hydration, which thins mucus in the airways.
2. Thinner mucus is easier to expectorate, aiding in clearing airway congestion.
3. Adequate hydration also helps to prevent dehydration, which can further thicken secretions.
Summary:
A: Maintaining a semi-Fowler's position may help with breathing comfort but does not directly address the issue of thick secretions.
B: Administering oxygen is important for COPD patients but does not specifically target bronchial secretions.
C: Selecting a low-salt diet is beneficial for managing fluid retention but does not directly address the issue of tenacious bronchial secretions.
Following treatment with fluoxetine, a selective serotonin reuptake inhibitor for depression, Mary hardly sleeps, is hyperactive, easily distracted, and appears elated. You would expect her physician to
- A. Continue the selective serotonin reuptake inhibitor.
- B. Start a mood stabilizer.
- C. Switch to a tricyclic antidepressant.
- D. Add a monoamine oxidase inhibitor.
Correct Answer: B
Rationale: Mood stabilizers are used to treat symptoms of mania or hypomania associated with bipolar disorder.
Stephen Douglas has been in an automobile accident. The most effective IV solution for a patient having hypovolemic shock would be:
- A. hypertonic.
- B. isotonic.
- C. hypotonic.
- D. colloids.
Correct Answer: B
Rationale: Hypertonic IV fluids would be used to draw fluid off tissue in edematous situations such as third spacing. Isotonic solutions are used to increase intravascular volume, to increase perfusion of vital organs. Hypotonic fluids are used to rehydrate tissue in those with severe, or prolonged fluid deprivation. Colloids increase tonicity of intravascular fluids, pulling water into the vascular system from tissue.