Nokea
The unlicensed assistive personnel (UAP) reported an intake of 1,000 mL and a urinary output of 1,500 mL for a client who received a thiazide diuretic this morning. Which nursing task could the nurse delegate to the nursing assistant?
- A. Instruct the UAP to restrict the client's fluid intake.
- B. Request the UAP to insert a Foley catheter with an urometer.
- C. Tell the UAP urinary outputs are no longer needed.
- D. Ask the UAP to document fluids on the bedside I & O record.
Correct Answer: D
Rationale: Documenting I&O is within UAP scope; fluid restriction, catheter insertion, or discontinuing monitoring require nursing judgment.
You may also like to solve these questions
The nurse has received the morning report and has the following medications due or being requested. In which order should the nurse administer the medications? List in order of priority.
- A. Administer furosemide (Lasix), a loop diuretic, IVP daily to a client diagnosed with heart failure who is dyspneic on exertion.
- B. Administer morphine, a narcotic analgesic, IVP prn to a client diagnosed with lower back pain who is complaining of pain at a '10' on a 1-to-10 scale.
- C. Administer neostigmine (Prostigmin), a cholinesterase inhibitor, PO to a client diagnosed with myasthenia gravis.
- D. Administer lidocaine, an antidysrhythmic, IVP prn to a client in normal sinus rhythm with multifocal premature ventricular contractions.
- E. Administer vancomycin, an aminoglycoside antibiotic, to a client diagnosed with a Staphylococcus infection who has a trough level of 14 mg/dL.
Correct Answer: B,D,A,C,E
Rationale: 1) Morphine for severe pain (acute, 10/10); 2) Lidocaine for PVCs (cardiac risk); 3) Furosemide for dyspnea (respiratory distress); 4) Neostigmine for myasthenia (muscle strength); 5) Vancomycin (infection, stable trough).
Ringer's lactate is running at 125 mL/hr. The administration set has 15 drops/mL. What should the drip rate be?
- A. 8 drops/min
- B. 31 drops/min
- C. 50 drops/min
- D. 67 drops/min
Correct Answer: B
Rationale: Divide 125 mL/hr by 60 min/hr and multiply by 15 drops/mL: (125 ÷ 60) × 15 = 31.25, rounded to 31 drops/min.
An adult client who has been taking furosemide (Lasix) 40 mg PO every day for several weeks is complaining of muscle weakness and lethargy. Which test will be of greatest value in assessing the client's condition?
- A. Serum electrolytes
- B. Urinalysis
- C. Serum creatinine
- D. Five-hour glucose tolerance test
Correct Answer: A
Rationale: Furosemide can cause hypokalemia, leading to muscle weakness and lethargy; serum electrolytes assess potassium levels.
The female client with Trichomonas vaginalis is prescribed metronidazole (Flagyl), an antibacterial medication. Which statement indicates the client does not understand the discharge teaching?
- A. I will not be able to drink any alcohol while taking this drug.
- B. My boyfriend will need to take this same medication.
- C. I cannot transmit the disease through oral sex.
- D. I must make sure I take all the pills no matter how I feel.
Correct Answer: C
Rationale: Trichomonas can be transmitted via oral sex; this statement shows misunderstanding. Alcohol avoidance, partner treatment, and full course completion are correct.
A 10-month-old child has been diagnosed as having acute otitis media. The pediatrician prescribed amoxicillin suspension. What instructions should the nurse give the child's mother?
- A. When your child's temperature has been normal for two days, discontinue the medicine.
- B. Discard any unused medication.
- C. If your child has symptoms of an ear infection again, start giving her the leftover medication.
- D. Give your child all of the medication in the bottle.
Correct Answer: B
Rationale: The nurse should instruct to discard unused medication to prevent misuse. The full course should be completed, but the bottle is only good for two weeks.