A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding

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.

Choice A reason:

Substitute tobacco use with an electronic cigarette Electronic cigarette, also known as e-cigarettes or vapes, are not recommended as a primary treatment for nicotine withdrawal. While they may be considered less harmful than traditional tobacco products, their long-term safety and effectiveness in helping individuals quit smoking are still a subject of debate and research. It is generally better to opt for proven nicotine replacement therapies, such as nicotine gum, patches, lozenges, or other medications approved by healthcare providers for smoking cessation.

Choice B reason:

Limitin use of nicotine gum to 6 months is the correct choice. When discussing treatment options with a client experiencing nicotine withdrawal, the nurse should include the information that the use of nicotine gum should be limited to 6 months. Nicotine gum is a form of nicotine replacement therapy (NRT) used to help individuals quit smoking by reducing withdrawal symptoms and cravings.

However, prolonged use of nicotine gum can lead to its own dependence on nicotine, which is counterproductive to the goal of quitting smoking altogether. The use of NRT is typically recommended for a limited duration, and the goal is to gradually reduce the dosage over time until the individual can comfortably quit nicotine use altogether.

Choice C reason:

Using progressively larger nicotine patches Using progressively larger nicotine patches is not a recommended approach for nicotine withdrawal. Nicotine patches are available in different strengths, and the appropriate dosage should be determined based on the individual's smoking history and nicotine dependence. Starting with the appropriate strength and gradually reducing the dosage over time is the preferred approach to help clients quit smoking.

Choice D reason:

Using up to 40 nicotine lozenges per day the use of nicotine lozenges should be guided by the instructions provided with the product or as prescribed by a healthcare provider. It is not advisable to exceed the recommended dosage. Using excessive amounts of nicotine lozenges or any other NRT product can lead to nicotine toxicity and other adverse effects.