Nokea
The nurse is caring for a client who is confused and is in soft wrist restraints. Which tasks can the nurse safely assign to unlicensed assistive personnel? Select all that apply.
- A. Assist the client with using a bedpan
- B. Check circulation and sensation of the extremities
- C. Perform range-of-motion exercises
- D. Report changes in skin integrity
- E. Turn and reposition the client in bed
Correct Answer: A,C,D,E
Rationale: UAP can assist with bedpan use (A), perform range-of-motion exercises (C), report skin changes (D), and reposition the client (E). Checking circulation and sensation (B) requires nursing assessment skills.
You may also like to solve these questions
The nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection?
- A. 51-year-old client who received a permanent pacemaker 48 hours ago
- B. 60-year-old client who had a myocardial infarction 24 hours ago
- C. 74-year-old client with stroke and an indwelling urinary catheter for 3 days
- D. 75-year-old client with dementia and dehydration who is on IV fluids
Correct Answer: C
Rationale: An indwelling urinary catheter increases the risk of catheter-associated urinary tract infections, a common nosocomial infection, especially in older adults with prolonged catheter use.
A client is taking tranylcypromine (Parnate) and has received dietary instruction. Which of the following food selections would be contraindicated for this client?
- A. Fresh juice, carrots, vanilla pudding
- B. Apple juice, ham salad, fresh pineapple
- C. Hamburger, fries, strawberry shake
- D. Red wine, fava beans, aged cheese
Correct Answer: D
Rationale: Red wine, fava beans, and aged cheese contain tyramine and other vasopressors that can interact with MAOIs, potentially causing malignant hypertension.
During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother?
- A. My child has lost 3 pounds in the last month.
- B. Urinary output seemed to be less over the past 2 days.
- C. All the pants have become tight around the waist.
- D. The child prefers some salty foods more than others.
Correct Answer: C
Rationale: All the pants have become tight around the waist. Increased abdominal girth is an early sign of Wilm's tumor.
The nurse is reinforcing teaching to an overweight 54-year-old client about ways to decrease symptoms of obstructive sleep apnea. Which interventions would be most effective? Select all that apply.
- A. Eating a high-protein snack at bedtime
- B. Limiting alcohol intake
- C. Losing weight
- D. Taking a mild sedative at bedtime
- E. Taking a nap during the day
- F. Taking modafinil at bedtime
Correct Answer: B,C
Rationale: Limiting alcohol (B) reduces airway relaxation, and losing weight (C) decreases airway obstruction, both directly alleviating sleep apnea symptoms.
During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time?
- A. leave a book about relaxation techniques
- B. write out a daily exercise routine for them to assist the client to do
- C. list actions to improve the client's daily nutritional intake
- D. suggest communication strategies
Correct Answer: D
Rationale: Alzheimer's disease, a progressive chronic illness, greatly challenges caregivers. The nurse can be of greatest assistance in helping the family to use communication strategies to enhance their ability to relate to the client.