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A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the documentation of clients' capillary glucose results rather than performing the test. What is the best action by the charge nurse to handle this situation?
- A. Ask a client if the UAP has performed the test
- B. Discuss the importance of task completion and accurate documentation in a staff meeting
- C. Give the UAP a verbal warning not to falsify data
- D. Take a client's capillary glucose personally and compare it to the recorded result
Correct Answer: D
Rationale: Verifying the glucose result personally (D) provides evidence of falsification. Asking a client (A) is unreliable, a staff meeting (B) is too general, and a warning (C) is premature without proof.
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Because a client is scheduled for a bronchoscopy tomorrow, the nurse should do which of the following?
- A. Encourage fluids before the procedure
- B. Keep the client NPO after midnight
- C. Give the client a cleansing enema this evening
- D. Withhold all medications the day before the procedure
Correct Answer: B
Rationale: Bronchoscopy involves sedation and airway manipulation, requiring NPO status after midnight to prevent aspiration, unlike fluids, enemas, or withholding medications.
The nurse is caring for a client with rheumatoid arthritis. Which of the following lifestyle modifications should the nurse recommend to the client?
- A. Avoid the use of ice on painful joints.
- B. Allow for periods of rest in the afternoon.
- C. Perform range-of-motion exercises daily.
- D. Place a pillow under the knees before sleep.
- E. Use moist heat packs to relax stiff joints as needed.
Correct Answer: B,C,E
Rationale: Rest (B), range-of-motion exercises (C), and moist heat (E) manage rheumatoid arthritis symptoms. Ice (A) can reduce inflammation, and a pillow under knees (D) may worsen stiffness.
The nurse has attended a staff education program about obtaining blood specimens from newborns via heel stick. Which of the following statements by the nurse would require follow-up?
- A. Nonnutritive sucking may help alleviate pain during the puncture.
- B. I will obtain the blood specimen from the center of the newborn's heel.
- C. I will wipe away the first drop of blood prior to obtaining the specimen.
- D. The heel area should be warmed for 3 to 5 minutes prior to the puncture.
Correct Answer: B
Rationale: The center of the heel (B) should be avoided to prevent bone injury; lateral or medial aspects are used. Sucking (A), wiping the first drop (C), and warming (D) are correct.
The nurse is caring for a client receiving peritoneal dialysis. Which findings are essential for the nurse to report to the health care provider?
- A. Cloudy outflow
- B. Low-grade fever
- C. Oliguria
- D. Pruritus
- E. Tachycardia
Correct Answer: A,B,E
Rationale: Cloudy outflow (A), fever (B), and tachycardia (E) suggest peritonitis, requiring immediate reporting. Oliguria (C) is expected in renal failure, and pruritus (D) is less urgent.
The nurse in a college health clinic is teaching the male students testicular self-examination. Which statement made by one of the young men indicates a need for more teaching?
- A. I should do a testicular self-examination every month.'
- B. When I am taking a shower is a good time to do the self-exam.'
- C. If I feel any lumps, I should report it to the physician.'
- D. Testicular cancer is usually found in older men.'
Correct Answer: D
Rationale: Testicular cancer primarily affects younger men (15–35 years), not older men, indicating a need for more teaching. Monthly exams, shower timing, and reporting lumps are correct.