Nokea
A confused client has been placed in physical restraints by order of the healthcare provider. Which task could be assigned to an unlicensed assistive personnel (UAP)?
- A. Assist the client with activities of daily living
- B. Monitor the client's physical safety
- C. Evaluate for basic comfort needs
- D. Document mental status and muscle strength
Correct Answer: A
Rationale: The correct answer is A: 'Assist the client with activities of daily living.' Unlicensed assistive personnel (UAP) can help clients with activities of daily living, such as feeding, bathing, and dressing. This task is appropriate for UAP as it does not require professional judgment. Choices B, C, and D involve monitoring safety, evaluating needs, and documenting assessments, which require a licensed nurse's professional judgment and expertise.
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The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?
- A. Expiratory wheezes
- B. Blurred vision
- C. Ascites
- D. Dilated pupils
Correct Answer: C
Rationale: Ascites is a common finding in clients with portal hypertension. Portal hypertension results in increased pressure in the portal vein, leading to the development of ascites, which is the accumulation of fluid in the abdominal cavity. Expiratory wheezes (Choice A) are associated with respiratory conditions. Blurred vision (Choice B) is more commonly linked to eye disorders or neurological issues. Dilated pupils (Choice D) can be related to neurological conditions or drug effects, but not specifically to portal hypertension.
The nurse manager has a nurse employee who is suspected of having a problem with chemical dependency. Which intervention would be the best approach by the nurse manager?
- A. Confront the nurse about the suspicions in a private meeting
- B. Schedule a staff conference, without the nurse present
- C. Consult the human resources department about the issue and needed actions
- D. Counsel the employee to resign to avoid investigation
Correct Answer: C
Rationale: Consulting with human resources is the best approach in this situation. It ensures that the issue is handled according to the organization's policies and that the nurse receives the appropriate support and intervention needed for chemical dependency. Confronting the nurse directly may lead to defensiveness and hinder a constructive resolution. Scheduling a staff conference without the nurse present can create unnecessary speculation and violate the employee's privacy. Counseling the employee to resign is not appropriate and does not address the underlying problem of chemical dependency.
The RN is making a home visit to a female client with end-stage heart disease. She has a living will and states she will never go back to the hospital. During the visit, the RN notes that the client is pale and SOB while speaking. The RN discovers 3+ edema in both ankles and bilateral pulmonary crackles. Which intervention should the RN implement first?
- A. Order a chest X-ray
- B. Obtain a peripheral O2 saturation reading
- C. Obtain an order for complete blood count
- D. Tell the patient to stay in bed
Correct Answer: B
Rationale: Obtaining a peripheral O2 saturation reading is the priority intervention in this scenario. It helps assess the client's oxygenation status quickly, which is crucial in a client with signs of respiratory distress, such as shortness of breath and bilateral pulmonary crackles. Ordering a chest X-ray (Choice A) may be necessary later but does not address the immediate need for oxygen assessment. Obtaining an order for a complete blood count (Choice C) is not the priority in this situation as it does not directly address the client's respiratory distress. Instructing the patient to stay in bed (Choice D) does not address the underlying issue of potential hypoxia and respiratory compromise.
During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?
- A. Pleuritic pain on inspiration
- B. Dry mucus membranes in the mouth
- C. A decrease in respiratory rate from 34 to 24
- D. Decrease in chest wall expansion
Correct Answer: D
Rationale: A decrease in chest wall expansion suggests that the client may be experiencing a serious complication, such as worsening pneumonia or respiratory failure, requiring immediate medical attention. This finding indicates a potential decrease in lung function, which could lead to respiratory distress. Pleuritic pain on inspiration may be related to the disease process but does not indicate an immediate need for intervention. Dry mucus membranes in the mouth may require attention but are not as critical as a decrease in chest wall expansion. A decrease in respiratory rate could be concerning but is not as urgent as a decrease in chest wall expansion, which directly impacts respiratory function.
Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. This action by the nurse will assess
- A. Right ventricular pressure
- B. Left ventricular end-diastolic pressure
- C. Acid-Base balance
- D. Coronary artery stability
Correct Answer: B
Rationale: The correct answer is B: Left ventricular end-diastolic pressure. Pulmonary capillary wedge pressure is used to assess left ventricular end-diastolic pressure. This measurement provides valuable information on the filling pressure of the left ventricle. Choices A, C, and D are incorrect because monitoring pulmonary capillary wedge pressure does not directly assess right ventricular pressure, acid-base balance, or coronary artery stability.