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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Correct Answer is D
Explanation
A. Fibromyalgia is not a contraindication for combination oral contraceptives.
B. Fibrocystic breast disease is not a contraindication, though it may require monitoring.
C. Renal calculi are not a contraindication for oral contraceptive use.
D. Hypertension is a contraindication because it increases the risk of cardiovascular complications when using combination oral contraceptives.
Correct Answer is A
Explanation
A. Sitting in a chair next to the bed provides a comfortable and professional setting, allowing the nurse to engage with the client at eye level.
B. Sitting on the bed may be seen as too informal and might invade the client’s personal space.
C. Standing at the side of the bed can create a sense of distance and is less personal.
D. Standing at the foot of the bed may make the nurse seem detached and less approachable.
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