Nokea
The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?
- A. Assign an RN to provide total care of the client
- B. Assign a nursing assistant to help the client with self-care activities
- C. Delegate complete care to an unlicensed assistive personnel
- D. Supervise a nursing assistant for skin care
Correct Answer: D
Rationale: Supervise a nursing assistant for skin care. The nursing assistant can inspect the skin while giving hygiene care, but the nurse should supervise skin care since assessment and analysis are needed.
You may also like to solve these questions
A health care agency has different receptacles for the various categories of institutional waste. Into which container should the nurse dispose of a suction canister used to collect bloody drainage from the client's NG tube?
- A. Injurious waste receptacle
- B. Hazardous waste receptacle
- C. Infectious waste receptacle
- D. Wastebasket in the client's bathroom
Correct Answer: C
Rationale: Blood and body fluids are classified as infectious waste, requiring disposal in the infectious waste receptacle.
A client being treated for hypertension returns to the community clinic for follow up. The client says, 'I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom.' Which of these is the best nursing diagnosis?
- A. Noncompliance related to medication side effects
- B. Knowledge deficit related to misunderstanding of disease state
- C. Defensive coping related to chronic illness
- D. Altered health maintenance related to occupation
Correct Answer: A
Rationale: Noncompliance related to medication side effects. The client kept his appointment, and stated he knew the pills were important. He is unable to comply with the regimen due to side effects, not because of a lack of knowledge about the disease process.
Which of these clients is the priority for the nurse to report to the public health department within the next 24 hours?
- A. An infant with a positive culture of stool for Shigella
- B. An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
- C. A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii
- D. A middle-aged nurse with a history of varicella zoster virus and with crops of vesicles on an erythematous base that appear on the skin
Correct Answer: B
Rationale: Tuberculosis is a reportable disease because persons who had contact with the client must be traced and often must be treated with chemoprophylaxis for a designated time.
A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with
- A. a Dopamine drip IV with vital signs monitored every 5 minutes
- B. a myocardial infarction that is free from pain and dysrhythmias
- C. a tracheotomy of 24 hours in some respiratory distress
- D. a pacemaker inserted this morning with intermittent capture
Correct Answer: B
Rationale: This client is the most stable with minimal risk of complications or instability. The nurse can utilize basic nursing skills to care for this client, making it suitable for a nurse from another unit.
A mother that has never breast-fed a child before is having trouble getting the baby to latch on to the breast. The baby has lost 3% of its birth weight within the first 2 days of life. The best statement is:
- A. The baby will eventually take to the breast.
- B. I can fix up a bottle if you want to try that.
- C. A small amount of weight loss in the first few days is normal.
- D. I can get the charge nurse to come and talk to you about breast-feeding.
Correct Answer: C
Rationale: 5-10% of birth weight loss following birth is normal for the first few days of life, and this response reassures the mother while allowing further discussion about breastfeeding challenges.