A nurse is caring for four clients on a surgical unit. Which of the following tasks should the nurse delegate to the assistive personnel (AP)?

Collect health history data from a client in Buck's traction for a fracture of the right hip.

Reinforce discharge teaching with a client who is 1 day postoperative following a total knee arthroplasty

Assist a client to a chair who is 2 days postoperative following a cervical laminectomy.

Administer pain medication to a client who has skeletal traction of the tibia

Answer and Explanation

The Correct Answer is C

A. Collecting health history requires nursing judgment and assessment skills, so it cannot be delegated to AP.
B. Reinforcing discharge teaching involves education and evaluation of understanding, which is within the nurse’s scope of practice.
C. Assisting a stable postoperative client to a chair is within the scope of practice for assistive personnel (AP), making this the correct delegation.
D. Administering medication, including pain medication, requires a licensed nurse and cannot be delegated to AP.

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Correct Answer is ["A","B","D"]

Explanation

A. Altered sensation (paresthesia) in the toes is an early sign of compartment syndrome caused by nerve compression.
B. Absence of pulse can indicate severe compartment syndrome with arterial compromise.
C. Pain from compartment syndrome is not relieved by narcotics; severe, unrelenting pain is a hallmark symptom.
D. Cool skin distal to the affected area indicates impaired perfusion, a complication of compartment syndrome.
E. Capillary refill of 1 second is normal and does not indicate compromised circulation.

A. Administer a sedative at bedtime. B. Place the bedside table within the client's reach. C. Keep the bed at a comfortable working height. D. Keep a night light on in the client's room and bathroom. E. Lock the wheels on beds and wheelchairs during transfers.

Correct Answer is ["B","D","E"]

Explanation

A. Sedatives can increase the risk of falls in older adults due to dizziness or impaired balance; they should not be used routinely for fall prevention.
B. Placing the bedside table within reach reduces the need for the client to stretch or get up frequently, lowering fall risk.
C. The bed should be kept in the lowest position, not a working height, to prevent falls when the client gets out of bed.
D. Night lights improve visibility and help prevent falls during nighttime ambulation.
E. Locking wheels on beds and wheelchairs during transfers ensures stability and safety, reducing fall risk.

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A nurse is caring for four clients on a surgical unit. Which of the following tasks should the nurse delegate to the assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing a neurovascular check for a client who had an open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)

Correct Answer is ["B","D","E"]

Explanation

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