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?

Observe the position of the suspended weight.

Check the client’s pedal pulse on the right leg.

Ask the client to describe her pain.

Remind the client to use the incentive spirometer.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. Remind the client to use the incentive spirometer.

Choice A rationale:

Observing the position of the suspended weight requires clinical judgment to ensure proper alignment and effectiveness of the traction, which is beyond the scope of practice for assistive personnel.

Choice B rationale:

Checking the client’s pedal pulse on the right leg involves assessing circulation, which is a clinical task that should be performed by a licensed nurse.

Choice C rationale:

Asking the client to describe her pain involves pain assessment, which requires clinical judgment and should be done by a nurse.

Choice D rationale:

Reminding the client to use the incentive spirometer is a task that can be delegated to assistive personnel as it involves reinforcing previously taught instructions without requiring clinical judgment.

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Correct Answer is A

Explanation

The correct answer is choicea. Maternal hypoglycemia.

Choice A rationale:

Maternal hypoglycemia can lead to decreased glucose availability for the fetus, which can result in fetal bradycardia.The fetus relies on maternal glucose for energy, and a significant drop in maternal glucose levels can affect the fetal heart rate.

Choice B rationale:

Maternal fever is typically associated with fetal tachycardia rather than bradycardia.An elevated maternal temperature can increase the fetal heart rate as the fetus attempts to regulate its own temperature.

Choice C rationale:

Chorioamnionitis, an infection of the amniotic fluid and membranes, is also more commonly associated with fetal tachycardia due to the inflammatory response and fever.

Choice D rationale:

Fetal anemia can cause fetal tachycardia as the fetus compensates for the reduced oxygen-carrying capacity of the blood.Bradycardia is not a typical response to fetal anemia.

A. Place sterile gauze over areas of spilled solution within the sterile field. B. Hold the irrigation solution bottle with the label facing away from the palm of the hand. C. Remove the cap and place it sterile-side up on a clean surface. D. Hold the bottle in the center of the sterile field when pouring the solution.

Correct Answer is C

Explanation

The correct answer is c. Remove the cap and place it sterile-side up on a clean surface.

Choice A rationale:

Placing sterile gauze over areas of spilled solution within the sterile field is incorrect. If solution is spilled within the sterile field, the entire field should be considered contaminated and a new sterile field should be set up

Choice B rationale:

Holding the irrigation solution bottle with the label facing away from the palm of the hand is incorrect. The label should face the palm of the hand to avoid contamination of the sterile field

Choice C rationale:

Removing the cap and placing it sterile-side up on a clean surface is correct. This ensures that the sterile side of the cap remains sterile and can be used to recap the bottle after pouring the solution

Choice D rationale:

Holding the bottle in the center of the sterile field when pouring the solution is incorrect. The bottle should be held over the edge of the sterile field to avoid contamination of the field if solution spills

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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 caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions is a possible cause of fetal bradycardia.

Correct Answer is A

Explanation

A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?

Correct Answer is C

Explanation

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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?