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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. The client's behavior should be assessed more frequently (e.g., every 15-30 minutes) during seclusion to ensure their safety.
B. Documenting the client's behavior prior to seclusion helps provide a clear rationale for the decision and the need for the intervention.
C. Discussing inappropriate behavior is not appropriate while the client is in seclusion and may exacerbate agitation.
D. Fluids should be offered more frequently than every 2 hours during seclusion to ensure hydration and comfort.

A. "The child usually has an aura prior to onset." B. "This type of seizure lasts 30 to 60 seconds." C. "This type of seizure has a gradual onset." D. "This type of seizure can be mistaken for daydreaming"

Correct Answer is D

Explanation

A. Absence seizures typically have no aura.
B. Absence seizures are brief, usually lasting 10-30 seconds, not 30 to 60 seconds.
C. The onset of absence seizures is sudden and brief, not gradual.
D. Absence seizures often appear as brief lapses in attention, which can be mistaken for daydreaming.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?

Correct Answer is B

Explanation

A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

Correct Answer is D

Explanation

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