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    Advanced Med Surghealth And Wellness Proctored Exam(Massachusetts College Of Pharmacy And Health Sciences)

    The nurse is caring for a client with chronic kidney disease after hemodialysis. Which action would the nurse delegate to the unlicensed assistive personnel (UAP)?

    Explanation & Rationale

    A. Measure the client’s postdialysis weight: Obtaining weight is a non-invasive, routine task that falls within the scope of UAP practice. Postdialysis weight is essential for evaluating fluid removal and estimating dry weight, but it does not require clinical judgment, making it appropriate for delegation. B. Assess for signs of disequilibrium syndrome: Disequilibrium syndrome involves neurologic manifestations such as headache, confusion, seizures, and decreased level of consciousness due to rapid osmotic shifts during dialysis. Recognizing these findings requires advanced assessment skills and clinical judgment, which must be performed by a licensed nurse. C. Monitor for signs of postdialysis bleeding: Clients are at increased risk for bleeding due to heparin use during dialysis and platelet dysfunction associated with uremia. Monitoring access sites for hemorrhage requires ongoing assessment and interpretation, which is beyond the UAP scope and must be done by the nurse. D. Educate the client on renal diet restrictions: Client education involves teaching complex dietary modifications related to sodium, potassium, phosphorus, and fluid balance. This requires knowledge of disease pathology and individualized planning, which must be performed by a licensed nurse.

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