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. The client's body should be placed on the floor: This is not a specific cultural practice in Islam. In Islamic tradition, the deceased person is usually placed on a raised surface, like a table or bed, to allow family and friends to gather around for prayers and final respects.
B. The client's oldest child will bathe the body: This is not a specific cultural practice in Islam.
In Islamic tradition, the body is usually washed by individuals of the same gender who are experienced in the ritual washing of the deceased, known as "Ghusl."
C. The client's face should be turned toward Mecca: Correct. In Islamic tradition, when a person dies, it is customary to position the body with the head facing the Kaaba in Mecca, which is the holy city in Islam and the direction toward which Muslims pray.
D. The client's body will be adorned with amulets: This is not a specific cultural practice in Islam. While some individuals in various cultures may use amulets or charms for protection, it is not a universal Islamic practice for the deceased.
Correct Answer is B
Explanation
A. Empty the urine drainage bag every 12 hours: While it's essential to empty the urine drainage bag regularly to prevent it from becoming too full, emptying it every 12 hours alone is not sufficient to prevent urinary tract infections (UTIs).
B. Drain the urine from the tubing before ambulation: Correct. Before the client ambulates or moves, the nurse should ensure that the urinary catheter's tubing is emptied. This prevents urine from flowing back into the bladder, reducing the risk of UTIs.
C. Use clean technique for urine specimen collection: While using clean technique during urine specimen collection is important for preventing contamination, it is not the primary action needed to prevent UTIs in a client with an indwelling urinary catheter.
D. Hang the urine drainage bag at the level of the bladder: While proper positioning of the drainage bag is essential for optimal urine flow and to prevent backflow, it alone is not sufficient to prevent UTIs.
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