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 A

Explanation

A. A light snack before bedtime, such as one containing tryptophan, can help promote sleep.
B. A 1-hour nap during the day could disrupt nighttime sleep patterns and should be avoided, especially in the late afternoon or evening.
C. Performing exercises prior to bedtime could be stimulating and might interfere with the ability to fall asleep.
D. Staying in bed for an hour if unable to fall asleep can reinforce frustration and poor sleep patterns. Instead, the client should get up and engage in a relaxing activity before trying to sleep again.

A. Don sterile gloves. B. Turn on the suction and set the pressure. C. Insert the catheter during the client's inspiration. D. Apply suction while rotating the catheter. E. Rinse the catheter to remove secretions.

Correct Answer is A,B,C,D,E

Explanation

A. The nurse should begin by donning sterile gloves to maintain a sterile field.
B. The suction machine should be turned on, and the pressure should be set before starting the suctioning.
C. The catheter should be inserted during the client’s inspiration to minimize discomfort and maximize
effectiveness.
D. Suction should be applied while rotating the catheter to prevent tissue damage and to clear secretions effectively.
E. After suctioning, the catheter should be rinsed to remove any remaining secretions.

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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 providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A,B,C,D,E

Explanation

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