Nokea
A nurse is working with an unlicensed assistive personnel (UAP) to perform a bed bath on a client. The nurse notes the smell of alcohol on the UAP's breath. Which is the priority nursing action?
- A. Work closely with the UAP during the shift and observe for any signs of impairment.
- B. Complete the bed bath without comment. The unit is already short one staff member.
- C. Offer chewing gum to the UAP. Since she does not give medications, she can do her job as she does not appear impaired.
- D. Call for another nurse to complete the bath and immediately report the UAP to the charge nurse or unit manager.
Correct Answer: D
Rationale: The smell of alcohol suggests potential impairment, which poses a safety risk to clients. Reporting to the charge nurse ensures client safety and follows protocol. Options A, B, and C fail to address the potential risk adequately.
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The nurse is responsible for his own actions while on duty caring for clients. What is the name of this ethical principle? Fill in the blank.
- A. Accountability
Correct Answer: A
Rationale: Accountability is the ethical principle where nurses are responsible for their own actions and decisions in client care.
The school nurse is monitoring the diet of a child with cystic fibrosis. Which type of diet would the family be advised to follow?
- A. low calorie, high fiber
- B. low fiber, low fat
- C. low sodium, gluten free
- D. high fat, high calorie
Correct Answer: D
Rationale: High-fat, high-calorie diets support nutritional needs in cystic fibrosis due to malabsorption.
An external weather disaster has flooded the emergency department with several new clients. Which client should the nurse see first?
- A. the client complaining of chest pain and nausea who is diaphoretic
- B. the client with a simple fracture of the radius from a fall on a staircase
- C. the client complaining of slight redness and itching at the IV site in his hand
- D. the client presenting with a sprained ankle from a tree branch falling on him
Correct Answer: A
Rationale: Chest pain, nausea, and diaphoresis suggest a potential myocardial infarction, a life-threatening condition requiring immediate attention. Options B, C, and D describe less urgent conditions.
A charge nurse is preparing client care assignments for the upcoming shift. A client who underwent a laminectomy is scheduled to return from the recovery care unit. Which staff member should receive this client?
- A. graduate nurse with 3 months of experience
- B. RN with 1 year of experience
- C. certified nursing assistant with 5 years of experience
- D. charge nurse with 2 years of experience
Correct Answer: B
Rationale: An RN with 1 year of experience has sufficient skills for post-laminectomy care. A CNA lacks the scope, and a graduate nurse may need more experience.
The charge nurse in the medical unit is preparing a bed assignment for a stable client diagnosed with necrotizing fasciitis. The client has a history of diabetes and hepatitis. There are four beds available. The nurse knows that the best roommate for this client is which of the following?
- A. a client with gout in the large toe
- B. a client with fever, vomiting, and diarrhea
- C. a client with MRSA
- D. a client with severe dementia with a tendency to wander
Correct Answer: A
Rationale: The gout client has a non-infectious condition, minimizing infection risk for the immunocompromised necrotizing fasciitis client.