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 A, B, C, D

Explanation

Sequence of Actions:

A: Evacuate clients from the area. This is the first and most crucial step to ensure the safety of all individuals in the vicinity of the fire.

B: Pull the lever on the fire alarm box. Once the immediate area is clear of individuals, the next step is to alert the rest of the building by activating the fire alarm system.

C: Close the fire doors on the unit. This action helps to contain the fire and prevent smoke from spreading to other areas, which can be vital in slowing the fire's progress and safeguarding other parts of the building.

D: Use a fire extinguisher to put out the fire. If the fire is small and contained, and the nurse is trained in its use, a fire extinguisher can be used to douse the flames, preventing further damage.

A. "This can help prevent nausea." B. "This can help prevent pneumonia." C. "I should do this every 4 hours." D. "I should do this to keep my heart from beating too fast."

Correct Answer is B

Explanation

A. "This can help prevent nausea." Turning, coughing, and deep breathing exercises are not primarily aimed at preventing nausea. These exercises are designed to maintain lung function and prevent respiratory complications.
B. "This can help prevent pneumonia." Correct. Turning, coughing, and deep breathing exercises are essential postoperative activities that help prevent the development of pneumonia by promoting lung expansion, clearing mucus, and preventing atelectasis.
C. "I should do this every 4 hours." The frequency of turning, coughing, and deep breathing exercises may vary based on individual client needs and surgical procedures. This statement does not demonstrate a specific understanding of the appropriate timing for these exercises.
D. "I should do this to keep my heart from beating too fast." Turning, coughing, and deep breathing exercises are not directly related to heart rate regulation. They are focused on lung expansion and airway clearance.

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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)?

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Explanation

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Explanation

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