A nurse is developing a care plan for a client who is in Buck's traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel?
Ask the client to describe her pain.
Check the client's pedal pulse on the right leg.
Observe the position of the suspended weight.
Remind the client to use the incentive spirometer.
The Correct Answer is D
A. Assessing pain requires clinical judgment and should be done by the nurse.
B. Checking pedal pulses is a nursing task that requires assessment of circulation and requires nursing expertise.
C. Observing the positioning of the weight is a task that requires an LPN or RN as it involves assessing the traction’s effectiveness.
D. Reminding the client to use the incentive spirometer is a task that can be delegated to an assistive personnel (AP) to help prevent respiratory complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A recent hip arthroplasty puts the client at risk for bleeding if alteplase is administered, as there is a potential for hemorrhage at the surgical site.
B. Acute renal failure may affect medication clearance but is not a contraindication for alteplase.
C. Chronic obstructive pulmonary disease (COPD) does not place the client at risk for alteplase therapy.
D. A family history of malignant hypertension does not directly affect the safety of alteplase therapy.
Correct Answer is B
Explanation
A. Epistaxis (nosebleeds) is not a common manifestation of hypovolemia. It is more typically associated with conditions like hypertension or nasal trauma.
B. Dizziness is a common symptom of hypovolemia due to reduced blood volume and decreased perfusion to the brain.
C. Shortness of breath is more likely to occur with conditions such as pulmonary edema or respiratory disorders, not hypovolemia.
D. Headache can occur in hypovolemia due to reduced blood flow, but dizziness is more directly related to the body's inability to compensate for low blood volume.
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