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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?

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

Answer and Explanation

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.

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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.

A. “The more my baby is at the breast sucking, the more milk I will produce.”. B. “Manually expressing my milk will decrease my milk supply C. "After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast.”. D. “My baby should always start on the same breast when feeding.”

Correct Answer is A

Explanation

The correct answer is choice A. “The more my baby is at the breast sucking, the more milk I will produce.” This statement indicates an understanding of the teaching because it reflects the principle of supply and demand in breastfeeding. The more the baby stimulates the breast, the more milk the mother will produce.

Choice B is wrong because manually expressing milk will not decrease the milk supply. In fact, it can help increase the milk supply by removing more milk from the breast and signaling the body to make more.

Choice C is wrong because the breast is not emptied after 5 to 10 minutes of feeding. The baby should be allowed to nurse until they are satisfied and show signs of fullness, such as releasing the nipple, falling asleep, or turning away from the breast. The average duration of a feeding session can vary from 10 to 45 minutes.

Choice D is wrong because the baby should not always start on the same breast when feeding. The mother should alternate which breast she offers first to ensure both breasts are stimulated and drained equally.

This can help prevent engorgement, mastitis, and low milk supply. A simple way to remember which breast to start with is to wear a bracelet or a clip on the bra strap on the side that needs to be offered next.

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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?

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client. Which of the following findings should the nurse report to the provider? (Click on the tabs belowfor additional information about the client. There are tabs that contain separate categories of data.) Exhibits Here

Correct Answer is B

Explanation

A nurse is teaching a new parent about breastfeeding her 2-week-old infant. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is A

Explanation

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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?