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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 C

Explanation

, dizziness.

Dizziness is a manifestation of hypovolemia, which is a decrease in blood volume due to fluid loss.

Hypovolemia can cause orthostatic hypotension, which is a drop in blood pressure when changing positions. This can lead to dizziness, lightheadedness, or fainting.

Choice A, epistaxis, is wrong because it is not a sign of hypovolemia, but rather a possible cause of it. Epistaxis is a nosebleed that can result from trauma, infection, dryness, or coagulation disorders.

Choice B, headache, is wrong because it is not a specific sign of hypovolemia, but rather a nonspecific symptom that can have many causes. Headache can be associated with dehydration, but it can also be caused by stress, infection, inflammation, or other factors.

Choice D, shortness of breath, is wrong because it is not a sign of hypovolemia, but rather a sign of fluid volume excess.

Fluid volume excess is an increase in blood volume due to fluid retention or overload. Fluid volume excess can cause dyspnea, which is difficulty breathing or shortness of breath.

Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg for adults.

Normal ranges for heart rate are 60 to 100 beats per minute for adults.

A. “I can apply heat for the first 24 hours to minimize the pain in my hand.” B. “I should not use my affected hand for 4 to 6 weeks.” C. “I should expect numbness and tingling in my hand.” D. “I will need to keep my hand elevated above my heart for several days.”

Correct Answer is D

Explanation

I will need to keep my hand elevated above my heart for several days.” This statement indicates that the client understands the importance of reducing swelling and inflammation in the affected hand after carpal tunnel surgery.

Elevation promotes venous return and prevents fluid accumulation in the tissues.

Choice A is wrong because applying heat for the first 24 hours can increase blood flow and swelling in the hand, which can cause more pain and delay healing. Ice packs are recommended for the first 24 to 48 hours to reduce inflammation.

Choice B is wrong because the client should not avoid using the affected hand for 4 to 6 weeks, as this can lead to stiffness, muscle atrophy, and decreased range of motion. The client should move the fingers periodically and perform gentle exercises as prescribed by the surgeon or physical therapist.

Choice C is wrong because numbness and tingling in the hand are signs of nerve compression, which is the main cause of carpal tunnel syndrome.

The client should expect these symptoms to improve or resolve after surgery, not persist or worsen. If the client experiences numbness and tingling after surgery, they should report it to the surgeon as it may indicate a complication such as nerve injury or hematoma.

Normal ranges for grip strength, pinch strength, and keypinch strength vary depending on age, sex, and hand dominance. However, a general reference for grip strength is 20 to 40 kg for men and 15 to 30 kg for women. For pinch strength, it is 6 to 12 kg for men and 5 to 10 kg for women. For keypinch strength, it is 4 to 8 kg for men and 3 to 7 kg for women.

These values may be lower in older adults or people with chronic conditions.

The client should expect some loss of strength in the affected hand after surgery, but it should gradually improve with rehabilitation.

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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 assessing a client who is experiencing hypovolemia. Which of the following manifestations should the nurse expect

Correct Answer is C

Explanation

A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

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?