A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?

Check the capillary refill every 4 hrs

Compare the pedal pulses every 4 hrs

Answer and Explanation

The Correct Answer is B

A. Check the capillary refill every 4 hrs Incorrect
The nurse should check capillary refill distally every 4 hr for a client whops elastic bandages on their lower extremities.

B. Compare the pedal pulses every 4 hrs CORRECT
The nurse should compare the pedal pulses bilaterally every week to check for adequate circulation for a client who has elastic bandages on their
lower extremities.

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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.

A. Ensure a client can use crutches before discharge. B. Check a client's ability to swallow following a stroke. C. Obtain a client's pain rating prior to physical therapy. D. Assist a client to get out of bed after a breathing treatment.

Correct Answer is D

Explanation

A: Incorrect. Ensuring a client can use crutches before discharge requires clinical judgment and skilled assessment, so it should not be delegated to assistive personnel.
B: Incorrect. Checking a client's ability to swallow following a stroke involves assessing the client's airway and potential risk of aspiration, which is a complex nursing task and should not be delegated to assistive personnel.
C: Incorrect. Obtaining a client's pain rating prior to physical therapy requires understanding the client's pain and its management, which should not be delegated to assistive personnel.
D: Correct. Assisting a client to get out of bed after a breathing treatment can be safely delegated to assistive personnel. It involves helping the client move, which is within the scope of their training.

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A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?

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