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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Alarm clock that shakes the bed: While a vibrating alarm clock can be helpful for waking a person with hearing loss, it may not be a priority modification for safety in the home environment.
B. Flashing smoke alarm: Correct. A flashing smoke alarm is a priority modification because it addresses the safety concern of alerting the client in the event of a fire or smoke in the home. The flashing light serves as an effective visual cue to notify the client about the danger.
C. Lowpitched buzzer doorbell: A lowpitched buzzer doorbell can be beneficial for individuals with hearing loss, but it is not as critical as having a flashing smoke alarm for immediate safety.
D. Telephone with an amplified receiver: An amplified telephone receiver can improve communication for clients with hearing loss but is not as essential for immediate safety as a flashing smoke alarm.

A. Neurological findings B. Incisional drainage C. Urinary output D. Reported pain level E. Gastrointestinal findings F. Vital signs

Correct Answer is ["C","D","F"]

Explanation

A: The neurological findings were already noted in the nurse's initial assessment, and the client's orientation and movement of extremities are within the expected range postoperatively.
Therefore, it does not require immediate reporting.
B: While the initial assessment indicated drainage on the dressing, there has been no further drainage since that time. A small amount of drainage following abdominal surgery is an expected finding and does not need to be reported to the provider unless drainage continues or increases over time.
C: Monitoring urinary output is essential, especially in a postoperative client, as it helps assess renal function and hydration status. Any significant changes in urinary output should be reported to the provider promptly.
D: The client's reported pain level of 6 on a scale of 0 to 10 indicates moderate pain, and the provider should be informed to address the pain and consider adjustments to the pain management plan.

E.Gastrointestinal assessment is incorrect. While nausea and hypoactive bowel sounds were initially noted, the client reports relief after the administration of metoclopramide.

F.Vital signs is correct. The client's heart rate and respiratory rate have increased, and their blood pressure and oxygen saturation levels have decreased. These findings should be reported to the provider.

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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