A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel (AP)?

Apply thromboembolic stockings.

Monitor the circulation in all four extremities.

Record the condition of the client's skin.

Answer and Explanation

The Correct Answer is A

A: Correct. Applying thromboembolic stockings (compression stockings) to the client's legs is a task that can be safely delegated to assistive personnel. The nurse should provide clear instructions on how to apply them properly.
B: Incorrect. Monitoring the circulation in all four extremities requires clinical judgment and skilled assessment, and it should not be delegated to assistive personnel.
C: Incorrect. Recording the condition of the client's skin requires observation and assessment, which should not be delegated to assistive personnel.

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Correct Answer is A

Explanation

A. The reduced muscle tone had relaxed the law muscles CORRECT
Prior to death, decreased muscle tone causes jaw muscles to relax resulting in an open mouth.

B. "That happens when a person gets close to death INCORRECT
This automatic response is nontherapeutic and does not address the family member's question

C. "I can apply a chin strap to help hold the mouth closed INCORRECT
Applying a chin strap is a postmortem action that the nurse can take to keep the mouth closed

A. Provide an artificial voice box. B. Avoid using facial gestures. C. Speak to the client in a louder voice. D. Ask the client close-ended questions.

Correct Answer is D

Explanation

A. Provide an artificial voice box - This is not typically used for clients with aphasia as it does not address the communication barriers they face.
B. Avoid using facial gestures - Facial gestures can be a helpful non-verbal communication tool, especially for clients with aphasia, so avoiding them is not beneficial.
C. Speak to the client in a louder voice - Aphasia affects language processing, not hearing, so increasing volume does not aid in understanding.
D. Ask the client close-ended questions - This allows the client to respond with 'yes' or 'no', or other simple answers, which can be easier for someone with aphasia.

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A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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