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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Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is C
Explanation
A. Sinus arrhythmia is typically not life-threatening and does not require immediate assessment unless other symptoms are present.
B. Epidural analgesia can cause some weakness in the lower extremities, but this is a known side effect and not an emergency.
C. Tachypnea, especially with a new onset in a client with a hip fracture, may indicate complications such as a fat embolism or pulmonary embolism, which require immediate assessment.
D. An HbA1c of 7.2% is slightly above the target but is not an immediate concern compared to other acute symptoms.
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