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 B

Explanation

The nurse should sit in a chair next to the bed to place the client at ease. This position allows the nurse to maintain eye contact, show interest, and respect the client’s personal space. Sitting on the bed next to the client (choice A) is wrong because it invades the client’s privacy and comfort zone. Standing at the side of the bed (choice C) or at the foot of the bed (choice D) is wrong because it creates a power imbalance and may intimidate the client.

The nurse should also consider the client’s condition and preferences when choosing a position for the interview. For example, a client who is on bedrest may have difficulty hearing or seeing the nurse if they are too far away or at an awkward angle.

Therefore, the nurse should adjust their position accordingly and ask the client if they are comfortable with it.

A. A client who is ambulatory and receiving oxygen. B. A client who uses a wheelchair and is confused. C. A client who is bedridden and wears a hearing aid. D. A client who has a fracture and is in balance suspension traction.

Correct Answer is A

Explanation

A client who is ambulatory and receiving oxygen should be evacuated first during a fire because they are at risk of fire and explosion from the oxygen source. The nurse should instruct the staff to turn off the oxygen supply, remove the oxygen device from the client, and assist them to walk out of the building using the nearest exit.
Choice B is wrong because a client who uses a wheelchair and is confused is not in immediate danger from the fire. They can be evacuated using a swing carry or an extremity carry by two staff members after the clients who are more vulnerable are evacuated.
Choice C is wrong because a client who is bedridden and wears a hearing aid is not in immediate danger from the fire. They can be evacuated using a cradle drop by one staff member after the clients who are more vulnerable are evacuated.
Choice D is wrong because a client who has a fracture and is in balance suspension traction is not in immediate danger from the fire. They can be evacuated using a special device such as a sked or a sled by two or more staff members after the clients who are more vulnerable are evacuated.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

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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?