A nurse is assigned to care for a 68-year-old adult client who had a right total hip arthroplasty (THA) 2 days ago on the medical-surgical unit. The client's pain is being managed with oral opioids and gabapentin. The client has been on apixaban 5 mg orally once a day and has ambulated with assistance 4 times each day in the hall with a walker.

For each client assessment finding, click which finding is associated with which potential client problem. Some findings may be consistent with more than one condition.

Complications of central venous access include thrombosis and malpositioning. Assessing localized edema requires objective measurement to quantify the extent of the vascular compromise. Nurses must apply the nursing process by performing a comprehensive assessment before implementing interventions or notifying the medical provider.

Choice A rationale

Measuring arm circumference provides baseline data to evaluate the severity of edema and possible deep vein thrombosis. Comparing bilateral measurements allows the nurse to quantify swelling, which is a critical assessment step before reporting findings to the physician.

Choice B rationale

Notification is necessary but should occur after the nurse has gathered objective data. Providing the clinician with specific measurements of arm circumference facilitates accurate clinical decision-making regarding potential complications like venous thrombosis or catheter-related mechanical infiltration.

Choice C rationale

Nurses generally do not remove PICC lines without a specific provider order unless there is an immediate, life-threatening emergency. Early removal without assessment might destroy vital venous access unnecessarily before the underlying cause of swelling is determined.

Choice D rationale

Cold packs cause vasoconstriction, which might be contraindicated if the swelling is due to a clot or specific medications. Interventions should only follow a complete assessment and verification of the underlying cause of the localized tissue swelling.

This question involves delegation principles in hospice care. Knowledge of the scope of practice for volunteers versus clinical staff is required. It focuses on identifying non-clinical, psychosocial support tasks appropriate for an unlicensed, non-medical volunteer to perform.

Choice A rationale

Providing spiritual support is a specialized role typically reserved for chaplains or trained clergy members. While volunteers are supportive, this task involves professional spiritual counseling and assessment beyond a general volunteer scope of practice.

Choice B rationale

Assessing the availability and functionality of medical equipment is a clinical responsibility. The nurse or a medical technician must ensure that the home environment is safe and that technical care requirements are met appropriately.

Choice C rationale

Personal care, such as sponge baths and skin assessments for bony prominences, involves physical contact and monitoring for skin breakdown. These tasks are typically delegated to nursing assistants or home health aides, not volunteers.

Choice D rationale

Volunteers in hospice are trained to provide companionship and emotional presence. Sitting with a client to reminisce provides psychosocial support and comfort, which falls within the volunteer's role of enhancing the client's quality of life.