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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This prescription is complete because it includes the medication name, dose, route, and frequency. A complete prescription should also include the client’s name, date, time, signature of the prescriber, and any special instructions.
Choice A is wrong because it does not specify the dose of cimetidine.
PO twice daily is not enough information to administer the medication safely. Choice B is wrong because it does not specify the frequency of tetracycline.
200 mg PO is not enough information to administer the medication safely. Choice C is wrong because it does not specify the route of epoetin alfa.
150 units/kg three times weekly is not enough information to administer the medication safely.
Normal ranges for digoxin are 0.5 to 2 ng/mL for heart failure and 0.8 to 2 ng/mL for atrial fibrillation.
Normal ranges for cimetidine are 50 to 150 ng/mL. Normal ranges for tetracycline are 1 to 10 mcg/mL.
Normal ranges for epoetin alfa are not applicable as it is a synthetic hormone that stimulates red blood cell production.
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.
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