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 B
Explanation
A. Advancing the catheter before releasing the tourniquet can increase the risk of trauma and difficulty in catheter placement.
B. Releasing the tourniquet is the correct step after confirming blood return to reduce venous congestion and ease the advancement of the catheter.
C. The stylet should not be retracted until the catheter is properly placed in the vein.
D. Flushing the catheter with saline should only be done once the catheter is properly secured in the vein.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
The client is at highest risk for developing mastitis as evidenced by the client'scracked nipple.
Rationale
The client has visible cracks on the left nipple, which is a key risk factor for mastitis. Cracked nipples can allow bacteria to enter the breast tissue during breastfeeding, leading to mastitis, especially if the nipples are not healing properly or the breastfeeding technique is suboptimal. The client also reports nipple discomfort throughout breastfeeding, which increases the likelihood of mastitis.
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