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 D

Explanation

A: A nasal cannula provides a low to moderate concentration of oxygen and is not suitable for a client experiencing severe difficulty breathing.
B: A simple face mask provides a higher concentration of oxygen than a nasal cannula but may not deliver a high enough concentration for a client experiencing severe respiratory distress.
C: A Venturi mask can provide a precise and adjustable concentration of oxygen but may not deliver the highest concentration needed in this scenario.
D: A nonrebreather mask can deliver the highest concentration of oxygen (up to 100%) and is the most appropriate choice for a client experiencing severe difficulty breathing.

A. Urine specific gravity 1.015 B. Hematocrit 42% C. Urine pH 6.5 D. BUN 5 mg/dL

Correct Answer is D

Explanation

A. A urine specific gravity of 1.015 is within the normal range (1.005–1.030). While fluid volume excess may lead to a lower specific gravity due to urine dilution, this value does not indicate fluid overload and is considered normal.
B. A hematocrit level of 42% is within the normal range for adults (men: 38–50%, women: 35–45%). Hematocrit levels tend to decrease in fluid volume excess due to hemodilution, but this value does not suggest fluid overload.
C. A urine pH of 6.5 is within the normal range (4.5–8.0). Urine pH reflects the acid-base balance rather than fluid status and is not a reliable indicator of fluid volume excess.
D. A BUN level of 5 mg/dL is below the normal range (10–20 mg/dL). In fluid volume excess, the dilution of blood plasma can lead to decreased BUN levels. This low BUN value, in conjunction with clinical symptoms, supports the diagnosis of fluid volume excess.

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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

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