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Which direction given to the nursing assistant is most likely to accomplish the task of getting a urine specimen delivered to the lab immediately after collection?
- A. Make it a stat delivery.'
- B. Please do it as soon as you can after break.'
- C. This client is delirious, and we're worried about a urinary sepsis.'
- D. Take this client to the bathroom now and collect a urine specimen from this voiding. Take the specimen to the lab immediately.'
Correct Answer: D
Rationale: Effective delegation depends on clear, concise direction that leaves no room for question or interpretation. The specific instruction to collect and deliver immediately ensures the task is prioritized.
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The LPN on shift notices a client come in to the clinic with bruises on his arm. The client seems very afraid and doesn't speak much which concerns the nurse because these are signs of physical abuse. The nurse should
- A. use therapeutic communication to talk to the client and attempt to get evidence of suspected abuse
- B. report the findings to the appropriate authorities based on the state requirements and protocols
- C. ignore the bruises, as this is not why the client is being treated and is not appropriate for the nurse to address
- D. report the suspected abuse to one of the other nurses and work together on how to handle it
Correct Answer: B
Rationale: It is the responsibility of any healthcare provider/team member to report any type of suspected abuse to the police or dictated agency per the state policy.
The nurse acts as an advocate for the nursing profession by performing all of the following activities except:
- A. encouraging political involvement by nurses with their legislators.
- B. acting as a first-aid provider for a children's athletic team.
- C. precepting newly licensed nurses in the work situation.
- D. encouraging as many persons to become nurses as possible.
Correct Answer: D
Rationale: The nurse acts as an advocate for the nursing profession by encouraging appropriate persons to become nurses, by being a positive role model and mentor, and by communicating the needs of nurses in the most professional manner possible, to those making the laws.
Rehabilitation services begin:
- A. when the client enters the health care system.
- B. after the client requests rehabilitation services.
- C. after the client's physical condition stabilizes.
- D. when the client is discharged from the hospital.
Correct Answer: A
Rationale: Rehabilitation services should begin when the client enters the health care system.
A client, age 28, is 8-12 months pregnant. She is most likely to display which normal skin-color variation?
- A. Vitiligo
- B. Erythema
- C. Cyanosis
- D. Chloasma
Correct Answer: D
Rationale: Chloasma, also known as the mask of pregnancy, is described as tan-to-brown patches on the face due to hormonal changes during pregnancy.
The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include?
- A. Use the defrost setting on microwave ovens to warm bottles.
- B. When refrigerating formula, don't feed the baby partially used bottles after 24 hours.
- C. When using formula concentrate, mix two parts water and one part concentrate.
- D. If a portion of one bottle is left for the next feeding, go ahead and add new formula to fill it.
Correct Answer: A
Rationale: Parents must be careful when warming bottles in a microwave oven because the milk can become superheated. When a microwave oven is used, the defrost setting should be chosen, and the temperature of the formula should be checked before giving it to the baby. Refrigerated, partially used bottles should be discarded after 4 hours because the baby might have introduced some pathogens into the formula. Returning the bottle to the refrigerator does not destroy pathogens. Formula concentrate and water are usually mixed in a 1:1 ratio of one part concentrate and one part water. Infants should be offered fresh formula at each feeding. Partially used bottles should not have fresh formula added to them. Pathogens can grow in partially used bottles of formula and be transferred to the new formula.