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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 assistive personnel?
- A. Ask the client to describe her pain.
- B. Check the client's pedal pulse on the right leg
- C. Observe the position of the suspended weight
- D. Remind the client to use the incentive spirometer.
Correct Answer: D
Rationale: Correct Answer: D. Remind the client to use the incentive spirometer.
Rationale:
1. Incentive spirometer use is a task that can be safely delegated to assistive personnel.
2. It is a non-invasive procedure and does not require advanced nursing skills.
3. Using the incentive spirometer helps prevent respiratory complications post-surgery.
4. Assistive personnel can remind the client to use it regularly, promoting lung expansion and preventing atelectasis.
Summary of other choices:
A: Asking the client to describe pain requires nursing assessment skills.
B: Checking the client's pedal pulse requires nursing assessment skills.
C: Observing the position of the suspended weight requires nursing judgment to adjust if needed.
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A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?
- A. Speak slowly when talking to the interpreter.
- B. Pause in the middle of sentences
- C. Speak directly to the client
- D. Use gestures to convey meaning
Correct Answer: C
Rationale: The correct answer is C: Speak directly to the client. This is important because even when using an interpreter, the nurse should maintain eye contact and address the client directly to establish trust and ensure the message is accurately conveyed. Speaking slowly (choice A) may be helpful, but it is not as crucial as direct communication. Pausing in the middle of sentences (choice B) could lead to confusion. Using gestures (choice D) may not always accurately convey the intended message. Therefore, speaking directly to the client is the most effective way to ensure clear communication and understanding.
For each assessment finding, click to specify if the finding is an indication of physical maltreatment, neglect, or financial maltreatment.
- A. Client reports having little food in the house.
- B. Client has bruises in various stages of healing.
- C. Client wears dirty clothing
- D. Client has no access to bank accounts
Correct Answer: A,B,C,D
Rationale: These findings suggest multiple forms of maltreatment.
Which of the following laboratory findings should the nurse expect following the transfusion?
- A. Increased platelets
- B. Increased Hct
- C. Decreased Hgb
- D. Decreased WBC count
Correct Answer: B
Rationale: The correct answer is B: Increased Hct. Following a transfusion, the nurse should expect an increase in hematocrit (Hct) levels due to the addition of packed red blood cells. This will result in an increase in the concentration of red blood cells in the blood, leading to a higher Hct value. The other choices are incorrect as: A) Increased platelets are not typically affected by a red blood cell transfusion, C) Decreased Hgb would not be expected as the purpose of the transfusion is to increase hemoglobin levels, and D) Decreased WBC count is unrelated to a red blood cell transfusion.
Which of the following findings is the nurse's priority?
- A. Constipation
- B. Sedation
- C. Bradypnea
- D. Euphoria
Correct Answer: C
Rationale: The correct answer is C: Bradypnea. Bradypnea, or slow breathing, is a critical finding that can indicate respiratory compromise and potentially lead to respiratory failure. It requires immediate attention to prevent further deterioration.
Constipation (A) is important but not as urgent as addressing a respiratory issue. Sedation (B) and euphoria (D) are side effects that may need monitoring but do not pose immediate threats to the patient's health.
In summary, addressing bradypnea is the priority to ensure the patient's respiratory function and prevent a life-threatening situation.
Which of the following actions should the nurse take?
- A. Encourage the client to watch television
- B. Administer a dose of atomoxetine to decrease anxiety
- C. Teach the client how to meditate
- D. Sit with the client to provide a sense of security.
Correct Answer: D
Rationale: Providing a calming presence can help de-escalate panic symptoms.