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 C
Explanation
A. Platelet count is important for assessing clotting, but INR is more relevant for monitoring warfarin therapy.
B. Fibrinogen levels are not the primary measure for warfarin management.
C. The INR (International Normalized Ratio) is the key test used to adjust warfarin dosing, as it measures the clotting tendency.
D. aPTT is useful for monitoring heparin therapy, not warfarin.
Correct Answer is C
Explanation
A. Repositioning without assistive devices can place undue strain on both the client and the nurse, especially after a stroke. Assistive devices should be used to maintain safety.
B. Client preferences are important, but repositioning schedules are primarily based on clinical needs such as skin integrity, circulation, mobility limitations, and prevention of pressure injuries.
C. Before repositioning a client who has had a stroke, the nurse should first assess the client’s strength, mobility, level of consciousness, and ability to assist with movement. This helps the nurse determine the safest repositioning method, the number of staff needed, and whether assistive devices are required. Assessment prior to movement reduces the risk of injury to both the client and the nurse.
D. Raising both side rails may increase the risk of injury or restrict movement. It’s safer to use one side
rail for support when repositioning.
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