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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Tell me what the afterlife means to you." Correct. This response demonstrates active listening and encourages the client to share their beliefs and feelings about the afterlife, providing the client with an opportunity for spiritual expression and understanding.
B. "You should discuss the afterlife with your priest." While discussing spiritual matters with a religious leader can be valuable, this response does not directly address the client's request for
the nurse to discuss the afterlife with them.
C. "Keep praying. A miracle could happen." This response may not fully address the client's need to discuss their beliefs about the afterlife. It focuses on hope but does not actively engage in the client's spiritual conversation.
D. "Maybe your condition will lead you closer to God." While offering comfort, this response may not meet the client's request to discuss the afterlife directly.
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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