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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Incorrect. Leaning on the crutches for support while standing still is not the correct way to use crutches. It can lead to discomfort and instability.
B: Correct. The client should advance the unaffected leg first while climbing stairs when using crutches. This technique ensures better stability and safety during stair ascent.
C: Incorrect. Standing 5 cm (2 in) from the front of a chair before sitting is not directly related to the use of crutches.
D: Incorrect. Bearing weight on the axilla while standing in the tripod position is not the correct way to use crutches. The tripod position is used for resting, not weight bearing.
Correct Answer is B
Explanation
A. Body regulation of heat and cold increases with age: This statement is incorrect. Age-related changes can lead to decreased efficiency in regulating body temperature, making older adults more susceptible to extreme temperatures.
B. Circulation becomes less efficient with age: Correct. With age, blood vessels can lose some of their elasticity, leading to decreased efficiency in circulating blood throughout the body. This can impact the ability to respond to temperature changes effectively.
C. Increased metabolic rate occurs with age, and increasing body temperature: This statement is incorrect. In general, metabolic rate tends to decrease with age, which can contribute to decreased heat production in older adults.
D. Sweat gland activity is increased with age: This statement is incorrect. Sweat gland activity tends to decrease with age, leading to decreased sweating and potential challenges in cooling the body during hot conditions.
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