A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel (AP)?
Apply thromboembolic stockings.
Monitor the circulation in all four extremities.
Record the condition of the client's skin.
The Correct Answer is A
A: Correct. Applying thromboembolic stockings (compression stockings) to the client's legs is a task that can be safely delegated to assistive personnel. The nurse should provide clear instructions on how to apply them properly.
B: Incorrect. Monitoring the circulation in all four extremities requires clinical judgment and skilled assessment, and it should not be delegated to assistive personnel.
C: Incorrect. Recording the condition of the client's skin requires observation and assessment, which should not be delegated to assistive personnel.
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Related Questions
Correct Answer is C
Explanation
A. Place the client's medication record on the bedside table while ambulating the client: This action does not relate to protecting the client's privacy. It might actually compromise confidentiality by leaving sensitive information exposed.
B. Give a report about the client's status while standing at the nurses' station: This action does not protect the client's privacy. Discussing sensitive information in a public area can lead to breaches of confidentiality.
C. Speak with the client about their condition after visitors have left: Correct. Protecting the client's privacy is essential, and discussing personal health information in private with the client respects their right to confidentiality.
D. Place a message board in the client's room to post dietary information: This action does not relate to protecting the client's privacy. Posting dietary information may be helpful for staff, but it doesn't address the client's privacy concerns.
Correct Answer is C
Explanation
A. The client has smooth, brown, irregular lesions on the back of each hand – These are likely seborrheic keratoses, which are benign, age-related lesions and do not usually require reporting unless changes suggest malignancy.
B. The client has glossy, white arches around the periphery of the corneas – This is commonly arcus senilis, a normal, benign finding in older adults that does not require intervention.
C. The client reports urinary incontinence – Urinary incontinence can be a sign of underlying issues such as a urinary tract infection or neurological disorder, necessitating further evaluation by the provider.
D. The client reports a decreased sense of taste – A reduced sense of taste is a typical age-related change and does not generally need to be reported unless it is sudden or associated with other symptoms.
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