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. Ask a family member who speaks the client's primary language to interpret: While involving family members may seem helpful, it is not the most effective way to ensure accurate and complete communication. There may be language barriers or misunderstandings.
B. Plan a long teaching session initially to introduce the necessary material: Lengthy teaching sessions may overwhelm the client and reduce their ability to absorb and retain information, especially when there is a language barrier.
C. Provide the least important information first: This approach is not recommended because it does not prioritize the client's understanding of essential preoperative instructions.
D. Provide handouts written in the client's primary language: Correct. Providing written materials in the client's primary language allows them to review the information at their own pace and increases the likelihood of understanding important preoperative instructions.

A. Check the pH of the gastric aspirate. B. Observe the color of the gastric aspirate after adding blue dye to the formula. C. Auscultate over the epigastrium. D. Measure the length of the inserted NG tube.

Correct Answer is A

Explanation

A: Correct. Checking the pH of the gastric aspirate is the most reliable method to verify the correct placement of the NG tube. Gastric aspirate typically has an acidic pH (pH < 5), indicating that the tube is in the stomach.
B: Observing the color of the gastric aspirate after adding blue dye to the formula is not a standard or recommended method for verifying NG tube placement.
C: Auscultating over the epigastrium may help to identify the presence of air in the stomach, but it does not confirm that the NG tube is correctly placed in the stomach or the intestines.
D: Measuring the length of the inserted NG tube can help determine the distance from the nose to the stomach, but it does not ensure correct placement in the stomach.

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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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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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