A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings
What action does the nurse delegate next to the UAP?
a.
Assess the client for pain or discomfort.
b.
Measure urine output from the catheter.
c.
Reposition the client to the unaffected side.
d.
Stay with the client and reassure him or her.
ANS: B
Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.
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