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 {"dropdown-group-1":"D","dropdown-group-2":"C"}
Explanation
Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and an increase in heart rate from 88 to 100.
Itching: itching is an immediate symptom of type 1 hypersensitivity reactions that are common with blood transfusion.
Correct Answer is B
Explanation
A. Keep the conversation moving by asking about the client's family: While engaging the client in conversation is important, this statement does not specifically address the client's difficulty in talking about their illness.
B. Let the client know that as their nurse, they are available and willing to listen: Correct. This response demonstrates the nurse's willingness to provide emotional support and active listening. Encouraging the client to express their feelings and concerns about their illness is essential in promoting therapeutic communication.
C. Ask if the client understands what to expect in the advanced stages of the illness: While discussing the client's understanding of their illness is essential, it does not directly address their difficulty in talking to others about it.
D. Ask the client's visitors not to say anything about the advanced disease: This response may hinder communication and restrict the client's opportunity to talk about their feelings and concerns with supportive visitors.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today