A nurse is developing a care plan for a client who is in Buck’s traction and is scheduled for surgery for a fractured femur of the right leg.
Which of the following interventions should the nurse delegate to an assistive personnel?
Observe the position of the suspended weight.
Check the client’s pedal pulse on the right leg.
Ask the client to describe her pain.
Remind the client to use the incentive spirometer.
The Correct Answer is D
The correct answer is choice D. Remind the client to use the incentive spirometer.
Choice A rationale:
Observing the position of the suspended weight requires clinical judgment to ensure proper alignment and effectiveness of the traction, which is beyond the scope of practice for assistive personnel.
Choice B rationale:
Checking the client’s pedal pulse on the right leg involves assessing circulation, which is a clinical task that should be performed by a licensed nurse.
Choice C rationale:
Asking the client to describe her pain involves pain assessment, which requires clinical judgment and should be done by a nurse.
Choice D rationale:
Reminding the client to use the incentive spirometer is a task that can be delegated to assistive personnel as it involves reinforcing previously taught instructions without requiring clinical judgment.
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Related Questions
Correct Answer is B
Explanation
The correct answer is choice b. Remove the device from the room.
Choice A rationale:
Reporting the defect to the equipment maintenance staff is important, but the immediate priority is to ensure the client’s safety by removing the faulty device.
Choice B rationale:
Removing the device from the room is the first action to take to prevent any potential electrical hazards or injuries to the client.
Choice C rationale:
Initiating a requisition for a replacement CPM device is necessary but should be done after the faulty device has been removed to ensure safety.
Choice D rationale:
Ensuring the device inspection sticker is current is part of routine checks, but it does not address the immediate safety concern posed by the frayed cord.
Correct Answer is D
Explanation
This prescription is complete because it includes the medication name, dose, route, and frequency. A complete prescription should also include the client’s name, date, time, signature of the prescriber, and any special instructions.
Choice A is wrong because it does not specify the dose of cimetidine.
PO twice daily is not enough information to administer the medication safely. Choice B is wrong because it does not specify the frequency of tetracycline.
200 mg PO is not enough information to administer the medication safely. Choice C is wrong because it does not specify the route of epoetin alfa.
150 units/kg three times weekly is not enough information to administer the medication safely.
Normal ranges for digoxin are 0.5 to 2 ng/mL for heart failure and 0.8 to 2 ng/mL for atrial fibrillation.
Normal ranges for cimetidine are 50 to 150 ng/mL. Normal ranges for tetracycline are 1 to 10 mcg/mL.
Normal ranges for epoetin alfa are not applicable as it is a synthetic hormone that stimulates red blood cell production.
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