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
None
None
The Correct Answer is D
The correct answer is D. Remind the client to use the incentive spirometer.
Choice A rationale:
Observing the position of the suspended weight is beyond the scope of practice for assistive personnel (AP). This task requires assessment skills to ensure proper alignment and functioning of the traction system, which is the responsibility of the nurse.
Choice B rationale:
Checking the client’s pedal pulse on the right leg involves assessment and clinical judgment to evaluate perfusion and detect potential complications such as impaired circulation. This is not a task that can be delegated to AP.
Choice C rationale:
Asking the client to describe her pain requires assessment and interpretation of subjective data, which falls under the nurse's scope of practice. Pain assessment is a critical nursing function.
Choice D rationale:
Reminding the client to use the incentive spirometer is a non-assessment task that involves reinforcing previously taught instructions. This is appropriate to delegate to assistive personnel, as it does not require clinical judgment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Urine specific gravity: The specific gravity of 1.035 indicates concentrated urine and might be indicative of dehydration. However, the nurse should address this finding by encouraging increased fluid intake before reporting it to the provider.
Choice B Reason:
Prealbumin: The prealbumin level is 25 mg/dL. Prealbumin is a marker of nutritional status and can indicate the adequacy of protein intake and overall nutritional status. A level of 25 mg/dL is relatively low, which may suggest malnutrition or insufficient protein intake. This finding should be reported to the provider so that appropriate interventions can be initiated to address the client's nutritional needs.
Choice C Reason:
Temperature: The temperature is not mentioned in the provided information. If the temperature is within the normal range, there is no need to report it to the provider.
Choice D Reason:
Blood pressure: The blood pressure is not mentioned in the provided information. If the blood pressure is within the normal range, there is no need to report it to the provider.
It's important for the nurse to critically assess the client's medical record and prioritize the findings that require immediate attention or intervention. In this case, the low prealbumin level indicates a potential nutritional issue that needs to be addressed promptly. The nurse should communicate this finding to the healthcare provider to ensure appropriate management and care for the client.
Correct Answer is C
Explanation
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