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 D rationale:
Reminding the client to use the incentive spirometer is an appropriate intervention for the nurse to delegate to assistive personnel. Using an incentive spirometer is a simple breathing exercise that helps prevent respiratory complications after surgery. Assistive personnel can provide reminders and encouragement to the client to use the incentive spirometer as directed, while the nurse focuses on more complex nursing interventions.
Choice A rationale:
Observing the position of the suspended weight is a critical aspect of Buck's traction management. The nurse should monitor this closely to ensure proper alignment and prevent complications. This intervention should not be delegated to assistive personnel.
Choice B rationale:
Checking the client's pedal pulse on the right leg is essential for monitoring circulation in the affected limb. Any changes in pulse quality or absence of a pulse could indicate a serious complication, such as compartment syndrome. This assessment should be performed by the nurse to ensure accurate findings and timely intervention if needed.
Choice C rationale:
Asking the client to describe her pain is part of the nursing assessment and should be done by the nurse. The nurse needs to assess the client's pain level, location, and characteristics to develop an appropriate pain management plan. Delegating this to assistive personnel could lead to inaccurate or incomplete information.
In summary, reminding the client to use the incentive spirometer is the only intervention that can be safely delegated to assistive personnel in this scenario, as it is a simple task that does not require nursing judgment or assessment. The other interventions are critical nursing responsibilities that should be performed by the nurse to ensure client safety and optimal outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B) I can visit my nephew who has chickenpox 5 days after the sores have crusted.
This statement indicates an understanding of infection prevention because it demonstrates knowledge about the contagious period of chickenpox. Visiting someone with chickenpox after the sores have crusted is a safe practice, as the person is no longer contagious.
The other options represent misconceptions about infection prevention:
A) Taking antibiotics for a viral infection is not effective, as antibiotics are used to treat bacterial infections, not viruses.
C) This statement is identical to option B and is incorrect.
D) Cleaning a cat's litter box during pregnancy is generally not recommended due to the risk of toxoplasmosis, a parasitic infection that can be transmitted through cat feces. Pregnant individuals are advised to have someone else handle cat litter or to use gloves and wash their hands thoroughly if they must do it themselves.
Correct Answer is C
Explanation
Choice A reason:
Administer epinephrine subcutaneously. This is not the necessary action to be taken. Epinephrine is used to treat severe allergic reactions (anaphylaxis). However, in this case, the client is experiencing a febrile non-haemolytic transfusion reaction, not an allergic reaction.
Choice B reason:
Place the blood bag in a biohazard bag before discarding. This is not the necessary action to be taken by the nurse. Proper disposal of biohazardous materials is essential, but in this situation, the nurse's priority is to address the client's condition and not the disposal of the blood bag
Choice C reason:
Documentation of the transfusion reaction is crucial for the client's medical history and for future reference. The nurse should record the client's signs and symptoms, the actions taken, and any other relevant information related to the reaction.
Choice D reason
Infuse 500 ml lactated Ringer's IV. This is not necessary action to be taken by the nurse because there is no indication for infusing lactated Ringer's solution in response to the transfusion reaction described. Treatment for febrile non-haemolytic transfusion reactions generally involves stopping the transfusion, administering antipyretics (like acetaminophen) if necessary, and providing supportive care as needed.
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