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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Determine the client’s knowledge about diaphragm use. This is the first action the nurse should take because it allows the nurse to assess the client’s readiness to learn, identify any knowledge gaps, and tailor the teaching to the client’s needs.
Some of the other choices are wrong because:
Choice A is wrong because Supervise return demonstration of diaphragm use.
This is not the first action the nurse should take because it assumes that the client already knows how to use the diaphragm correctly and safely. The nurse should first teach the client how to insert, remove, and care for the diaphragm before asking for a return demonstration.
Choice C is wrong because Document the client’s level of understanding about potential adverse effects.
This is not the first action the nurse should take because it is part of the evaluation phase of teaching, not the assessment phase. The nurse should first determine what the client knows and needs to know about diaphragm use and its possible risks and benefits.
Choice D is wrong because Teach the client how to insert the diaphragm.
This is not the first action the nurse should take because it is part of the implementation phase of teaching, not the assessment phase. The nurse should first assess the client’s knowledge, motivation, and preferences before providing instruction on how to use the diaphragm.
A contraceptive diaphragm is a birth control device that prevents sperm from entering the uterus.
It is a small, soft silicone or rubber cup with a flexible rim that covers the cervix.
It is inserted into the vagina with spermicide before sex and is held in place by the pelvic muscles. It is a reusable type of contraception that women can use to avoid getting pregnant.
Correct Answer is A
Explanation
These are signs of severe dehydration in an infant, which can be life-threatening and should be reported to the provider immediately. The infant may need intravenous fluids and electrolytes to restore hydration and prevent complications.
Choice B is wrong because a temperature of 38° C (100.4° F) and a pulse rate of 124/min are not abnormal for an infant and do not indicate severe dehydration. These are common findings in an infant who has gastroenteritis, which is an inflammation of the stomach and intestines caused by a virus, bacteria, or parasite.
Choice C is wrong because decreased appetite and irritability are also common findings in an infant who has gastroenteritis, but they do not indicate severe dehydration. The nurse should encourage oral rehydration with fluids such as breast milk, formula, or oral electrolyte solution.
Choice D is wrong because pale skin and a 24-hr fluid deficit of 30 mL are not signs of severe dehydration in an infant.
A fluid deficit of 30 mL is less than 1 oz and is not significant for an infant who weighs about 10 kg (22 lbs). A fluid deficit of more than 10% of body weight would indicate severe dehydration.
Normal ranges for vital signs in infants are as follows:
• Temperature: 36.5° C to 37.5° C (97.7° F to 99.5° F)
• Pulse rate: 100 to 160/min
• Respiratory rate: 30 to 60/min
• Blood pressure: 65/41 to 100/50 mm Hg
Normal ranges for fluid intake and output in infants are as follows:
• Fluid intake: 100 to 150 mL/kg/day
• Fluid output: 1 to 2 mL/kg/hr
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