Electrolytes Question #41

Question

The nurse and an unlicensed nursing assistant are caring for a group of clients. Which nursing intervention should the nurse perform?

Answers

  1. Measure the client's output from the indwelling catheter.
    • Rationale:
  2. Record the client's intake and output on the I & O sheet.
    • Rationale:
  3. Instruct the client on appropriate fluid restrictions.
    • Rationale:
  4. Provide water for a client diagnosed with diabetes insipidus.
    • Rationale:

Overview

Explanation

The correct answer is C. When providing care with an unlicensed nursing assistant, remember what can and cannot be delegated. Teaching is always done by a nurse. An unlicensed nursing assistant can measure output from an indwelling catheter, record intake and output, and provide water to a client.

NCLEX TIP: Using critical thinking is recommended when reading priority questions. Recognizing key words in the answer choices will allow you to know how to choose the correct answer for the question. Go through each answer choice and decide is it: Maslow’s hierarchy, safety-related, or following the nursing process (ADPIE). Never complete a nursing action that is outside the scope of practice.

Learning Outcomes

Test Taking Tip

Video Rationale