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

Hct stands for hematocrit, which is the percentage of red blood cells (RBCs) in the blood. A client who received 2 units of packed RBCs should have an increased Hct because they have more RBCs in their blood volume.

The normal range for Hct is 38% to 50% for males and 36% to 44% for females.

Choice B is wrong because decreased Hgb means decreased hemoglobin, which is the protein that carries oxygen in the RBCs.

A client who received 2 units of packed RBCs should have an increased Hgb because they have more hemoglobin in their blood. The normal range for Hgb is 13.5 to 17.5 g/dL for males and 12 to 15.5 g/dL for females.

Choice C is wrong because increased platelets means increased thrombocytes, which are the cells that help with blood clotting.

A client who received 2 units of packed RBCs should not have an increased platelet count because they did not receive platelets in the transfusion. The normal range for platelets is 150,000 to 400,000/mm^3.

Choice D is wrong because decreased WBC count means decreased leukocytes, which are the cells that fight infection and inflammation.

A client who received 2 units of packed RBCs should not have a decreased WBC count because they did not receive WBCs in the transfusion. The normal range for WBC count is 4,500 to 11,000/mm^3.

A. INR. B. Fibrinogen level. C. aPTT. D. Platelet count.

Correct Answer is A

Explanation

Warfarin is a vitamin K antagonist that inhibits the synthesis of factors II, VII, IX, and X in the liver. These factors are part of the extrinsic and common pathways of coagulation, which are measured by the prothrombin time (PT) and the international normalized ratio (INR). The INR is a standardized way of reporting the PT that accounts for the variability of different reagents and instruments. The INR is used to monitor the therapeutic effect of warfarin and to adjust the dose accordingly. The target INR range depends on the indication for warfarin, but it is usually between 2 and 3 for most conditions.

Choice B is wrong because fibrinogen level is not affected by warfarin.

Fibrinogen is a precursor of fibrin, which forms the final step of the coagulation cascade.

Fibrinogen level can be decreased in conditions such as disseminated intravascular coagulation (DIC), liver disease, or severe bleeding.

Choice C is wrong because aPTT is not affected by warfarin.

aPTT measures the intrinsic and common pathways of coagulation, which are mainly dependent on factors VIII, IX, XI, and XII.

These factors are not inhibited by warfarin.

aPTT is used to monitor the effect of heparin, a direct antithrombin agent that inhibits thrombin and factor Xa.

Choice D is wrong because platelet count is not affected by warfarin.

Platelets are cell fragments that adhere to damaged blood vessels and form aggregates to initiate hemostasis.

Platelet count can be decreased in conditions such as immune thrombocytopenia (ITP), heparin-induced thrombocytopenia (HIT), or bone marrow suppression.

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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?

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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?