🔷 Collecting a urine specimen is appropriate to delegate to assistive personnel because it is a routine, standard task that does not require nursing judgment or interpretation.

🔷 Delegation is appropriate when the task is predictable, has a low risk of harm, and does not involve assessment, teaching, or evaluation.

🔷 A urine specimen can be collected by assistive personnel and then reported to the nurse for follow-up as needed.

🔷 The nurse remains responsible for interpreting the results and deciding whether further intervention is necessary.

🔷 For this reason, collecting a urine specimen is the best task to delegate.

Measuring a client's pain level

🔷 Pain level is considered part of client assessment, and assessment data require nursing judgment.

🔷 Because the nurse must analyze the pain finding and determine the appropriate response, this task should not be delegated to assistive personnel.

Monitoring blood glucose levels

🔷 Blood glucose monitoring is not the best answer for assistive personnel in this question because it is commonly identified in nursing scope documents as a task performed by licensed nursing personnel such as an LPN/VN, not the simplest UAP delegation choice here.

🔷 The safest clearly appropriate delegated task from the options is urine specimen collection, which does not involve direct interpretation of potentially unstable metabolic findings.

Adjusting the flow rate of a client's oxygen tank

🔷 Adjusting oxygen flow rate involves changing a treatment and requires clinical judgment and provider-prescribed parameters.

🔷 This is not an appropriate task to delegate to assistive personnel because incorrect oxygen adjustment can harm the client.

🔶 Sitting with a client who has anorexia nervosa during meals is an appropriate task for assistive personnel because it is a supportive, routine observation role.

🔶 This task helps reinforce meal supervision and safety without requiring independent nursing assessment or legal responsibility.

🔶 The nurse can delegate the observation component while remaining responsible for evaluating intake, behavior, and clinical response.

🔶 In mental health settings, assistive personnel are often appropriate for structured, predictable support activities.

🔶 For this reason, sitting with a client who has anorexia nervosa during meals is the best task to delegate.

Obtain the vital signs of a client who has experienced a seizure

🔶 A client who has experienced a seizure may be unstable and requires nursing assessment and judgment about complications and neurologic status.

🔶 Because of the potential for rapid changes in condition, this task should not be delegated as the best option in this situation.

Witness a client's signature on an informed consent document

🔶 Witnessing informed consent is not a task for assistive personnel because it involves legal and ethical responsibilities tied to confirming the client’s voluntary signature and readiness.

🔶 This responsibility should be handled according to facility policy by appropriate licensed personnel.

Complete an incident report following a client fall

🔶 Completing an incident report is not delegated to assistive personnel because it requires documentation by licensed staff involved in the event and follow-up through the nursing process.

🔶 The nurse is responsible for assessment, documentation, and reporting after a client fall.

Compartment syndrome

🔷 The client is most likely experiencing compartment syndrome because the findings show numbness and tingling, severe pain 9/10, decreased right pedal pulse, cool skin, and a hard swollen extremity.

🔷 Compartment syndrome occurs when pressure builds up within a closed muscle compartment and begins to impair circulation and nerve function.

🔷 One of the earliest and most important signs is pain that becomes severe and is out of proportion to the expected postoperative course.

🔷 The progression from a stable assessment at 0700 to worsening neurovascular findings at 1700 strongly supports acute compartment syndrome rather than a routine postoperative change.

🔷 For these reasons, compartment syndrome is the condition the nurse should recognize immediately.

Osteomyelitis

🔷 Osteomyelitis is a bone infection and usually develops with findings such as fever, elevated WBC count, and localized infection signs rather than sudden neurovascular compromise.

🔷 This client’s most urgent findings are hard cool skin, severe pain, tingling, and reduced pulse, which fit compartment syndrome more closely.

Cellulitis

🔷 Cellulitis usually causes redness, warmth, tenderness, and swelling from a soft tissue infection.

🔷 This client’s extremity is cool, not warm, and the presence of neurovascular changes points away from cellulitis.

Deep vein thrombosis

🔷 Deep vein thrombosis can cause pain, swelling, and warmth, but it does not usually cause a hard compartment, marked neurologic symptoms, and worsening arterial perfusion signs like this.

🔷 The combination of coolness, paresthesia, and decreased pulse is more consistent with compartment syndrome than DVT.

Actions

Loosen surgical dressings.

🔶 The nurse should loosen surgical dressings because tight dressings can worsen pressure within the affected compartment.

🔶 In compartment syndrome, any external constriction can further impair blood flow and increase tissue ischemia.

🔶 Loosening restrictive dressings is an immediate nursing intervention to help reduce added compression while the provider is notified.

🔶 This action does not cure compartment syndrome, but it can help prevent further loss of circulation while urgent treatment is arranged.

🔶 For these reasons, loosening surgical dressings is an appropriate action.

Remove pillow elevating right lower extremity.

💎 The nurse should remove the pillow elevating the right lower extremity because excessive elevation can reduce arterial blood flow to an already compromised limb.

💎 In suspected compartment syndrome, the extremity should be kept at heart level, not elevated high above it.

💎 Keeping the leg too high can worsen ischemia by decreasing perfusion to tissues that are already under pressure.

💎 This client already has cool skin, decreased pulse, numbness, and severe pain, all of which show impaired circulation.

💎 For these reasons, removing the pillow elevating the right lower extremity is an appropriate immediate action.

Draw blood for PT and PTT.

🔶 PT and PTT are clotting studies and are not the priority intervention for a client showing classic signs of acute compartment syndrome.

🔶 The immediate concern is restoring and protecting neurovascular perfusion, not evaluating coagulation status.

Prepare to insert a peripherally inserted central catheter.

🔶 A PICC line is not an immediate intervention for acute compartment syndrome.

🔶 This action does not address the urgent problem of increasing compartment pressure and threatened circulation.

Prepare for administration of corticosteroids.

🔶 Corticosteroids are not the standard priority treatment for compartment syndrome.

🔶 The problem is mechanical pressure inside the compartment, which requires pressure relief rather than steroid therapy.

Parameters

Increasing pain level

✅ Increasing pain level is one of the most important parameters to monitor because worsening pain is a key sign that compartment pressure is rising.

✅ Pain in compartment syndrome is often severe, persistent, and greater than expected for the injury or surgery.

✅ The change from pain 4/10 at 0700 to pain 9/10 at 1700 already shows significant deterioration.

✅ Monitoring pain trends helps the nurse evaluate whether the condition is improving or progressing despite interventions.

Capillary refill

🟣 Capillary refill should be monitored because it reflects the adequacy of peripheral perfusion to the affected extremity.

🟣 In compartment syndrome, rising pressure decreases blood flow, which can delay capillary refill.

🟣 Monitoring capillary refill helps the nurse identify whether circulation is worsening or improving after interventions.

🟣 This parameter works together with pulse, skin temperature, sensation, and pain to evaluate the neurovascular status of the limb.

🟣 For these reasons, capillary refill is an important parameter to monitor.

✅ For these reasons, increasing pain level is an essential parameter to monitor.

WBC count

✅ WBC count is more helpful when monitoring for infection, such as cellulitis or osteomyelitis, than for compartment syndrome.

✅ This client’s urgent problem is impaired perfusion and nerve compression, not an infectious process.

Level of consciousness

✅ Level of consciousness is always important in general assessment, but it is not one of the most specific parameters for tracking the progress of compartment syndrome in this extremity.

✅ Neurovascular changes in the affected limb are more directly useful than mental status for evaluating this condition.

🔷 A speech-language pathologist should be consulted for a client who has difficulty swallowing because this specialist evaluates and treats dysphagia.

🔷 Swallowing problems increase the risk for aspiration, choking, malnutrition, and dehydration.

🔷 The speech-language pathologist can assess the client’s swallow reflex, recommend safe food textures, and teach swallowing techniques.

🔷 This referral is especially important when oral intake is unsafe or ineffective.

🔷 For these reasons, a client who has difficulty swallowing is the client who needs referral to a speech-language pathologist.

A client who requires special eating utensils

🔷 A client who needs special eating utensils is more appropriate for referral to occupational therapy.

🔷 Occupational therapists help clients adapt self-feeding and daily living tasks through assistive devices.

A client who has progressive muscle weakness

🔷 Progressive muscle weakness is more commonly addressed initially by physical therapy or by the provider depending on the cause.

🔷 This finding does not specifically point to the need for a speech-language pathologist unless swallowing or speech is also impaired.

A client who requires oxygen during ambulation

🔷 A client who needs oxygen during ambulation is more appropriate for respiratory support and mobility planning, not speech therapy.

🔷 This need is more closely associated with respiratory therapy or physical rehabilitation services.

🔶 A social worker is the most appropriate referral for a client requesting family therapy because social workers commonly provide counseling and connect families with mental health resources.

🔶 They help clients address family conflict, coping issues, communication problems, and psychosocial stressors.

🔶 Social workers also coordinate care and connect the client to community-based therapy services when needed.

🔶 This role fits the client’s request for family-focused emotional and relational support.

🔶 For these reasons, the nurse should initiate a referral to the social worker.

Occupational therapist

🔶 An occupational therapist focuses on improving functional ability in activities of daily living.

🔶 This discipline is not the primary resource for family therapy.

Recreational therapist

🔶 A recreational therapist uses leisure activities to improve well-being and function.

🔶 This team member is not the main professional to arrange family counseling or therapy.

Paramedical technologist

🔶 A paramedical technologist does not provide family therapy or counseling services.

🔶 This role is unrelated to the client’s request for psychosocial intervention.

💎 In right ventricular heart failure, blood backs up into the systemic venous circulation, which can enlarge the liver and spleen.

💎 This backup causes congestion in abdominal organs and leads to findings such as hepatomegaly, splenomegaly, ascites, and peripheral edema.

💎 Hepatosplenomegaly is therefore an expected manifestation of right-sided heart failure.

💎 Right-sided failure is more associated with systemic congestion than with pulmonary fluid buildup.

💎 For these reasons, hepatosplenomegaly is the expected finding.

Crepitus

💎 Crepitus is not a typical manifestation of right ventricular heart failure.

💎 It is more commonly associated with joint problems, fractures, or air in soft tissues.

Elevated pulmonary artery pressure

💎 Elevated pulmonary artery pressure may contribute to right-sided heart failure, but it is not the most direct expected physical finding asked for here.

💎 The clearer client finding of right-sided systemic congestion is hepatosplenomegaly.

Confusion

💎 Confusion can occur with poor perfusion or hypoxia, but it is not the classic hallmark finding of right ventricular failure.

💎 Right-sided failure more commonly presents with systemic venous congestion.

✅ Pertussis requires droplet precautions because it spreads through respiratory droplets produced by coughing and sneezing.

✅ Droplet precautions help prevent transmission to staff, other clients, and visitors.

✅ A client with pertussis should be placed in a private room when possible, and staff should wear a mask when entering.

✅ Early isolation is important because pertussis is highly contagious.

✅ For these reasons, the nurse should implement droplet precautions for pertussis.

Varicella-zoster

✅ Varicella-zoster requires airborne and contact precautions, not droplet precautions alone.

✅ This is because the virus can remain suspended in the air and also spread by direct contact.

Vancomycin-resistant enterococcus (VRE)

✅ VRE requires contact precautions because it spreads through direct contact with contaminated hands or surfaces.

✅ Droplet precautions are not the correct isolation category for VRE.

Rotavirus

✅ Rotavirus requires contact precautions because it spreads through the fecal-oral route and contaminated surfaces.

✅ Droplet precautions are not the primary isolation method for this infection.

🟣 If a client in skeletal traction reports pain from muscle spasms, the nurse should first assess alignment and realign the extremity in traction if needed.

🟣 Muscle spasms can occur when the traction is not maintaining proper alignment of the fractured bone and surrounding muscles.

🟣 Correct alignment helps reduce muscle tension and improves the effectiveness of traction.

🟣 The nurse should maintain the prescribed traction setup while ensuring the line of pull is correct.

🟣 For these reasons, realigning the extremity in traction is the appropriate action.

Remove the traction weights

🟣 The nurse should not remove the traction weights unless there is a specific provider prescription.

🟣 Removing the weights interrupts the therapeutic pull and can worsen pain and fracture alignment.

Increase the amount of traction

🟣 The nurse should not independently increase the traction weight because this requires a provider prescription.

🟣 Increasing the force can cause harm and is not a routine nursing response to muscle spasms.

Allow the weights to rest on the floor

🟣 Traction weights must hang freely to maintain constant therapeutic pull.

🟣 Letting them rest on the floor makes the traction ineffective.

🔵 Atorvastatin is contraindicated or used with extreme caution in clients with active liver disease, including hepatitis C with liver involvement, because statins can affect liver function.

🔵 This medication is metabolized in the liver and may worsen hepatic injury or increase liver enzyme levels.

🔵 Clients with liver disease have a greater risk of adverse effects when taking statins.

🔵 Before starting atorvastatin, the nurse should consider the client’s hepatic status carefully.

🔵 For these reasons, hepatitis C is the contraindicating condition among the options provided.

Crohn's disease

🔵 Crohn’s disease is not a direct contraindication to atorvastatin.

🔵 Although overall medication tolerance should be monitored, this condition does not specifically prevent statin use.

Peptic ulcer disease

🔵 Peptic ulcer disease is not a primary contraindication to atorvastatin.

🔵 Statins are more concerning in clients with hepatic disease than in those with gastric ulcer history.

Bronchitis

🔵 Bronchitis does not contraindicate the use of atorvastatin.

🔵 This respiratory condition is unrelated to the major safety concern of liver toxicity with statins.

⭐ Chondroitin and glucosamine are commonly used to support joint health and may help improve joint comfort and function, especially in osteoarthritis.

⭐ These supplements are thought to support cartilage structure and reduce joint stiffness in some clients.

⭐ They are not a cure, but some clients report mild improvement in mobility and pain.

⭐ Their intended use is musculoskeletal rather than psychiatric, immune, or prostate-related.

⭐ For these reasons, the health benefit of this supplement combination is to improve joint functioning.

Treat mild to moderate depression

⭐ Chondroitin and glucosamine are not used to treat depression.

⭐ Their primary role is related to joint support, not mood management.

Enhance the immune system

⭐ These supplements are not primarily taken to enhance immune function.

⭐ Their most common use is for joint and cartilage support.

Prevent and treat prostate enlargement

⭐ Prostate enlargement is not the therapeutic target of chondroitin and glucosamine.

⭐ These supplements are used for joint symptoms, not urinary or prostate disorders.