Nokea
A child is admitted to the pediatric unit after being diagnosed with pertussis. The nurse observes an unlicensed assistive personnel (UAP) donning a pair of gloves before entering the room to give the child a popsicle. Which action should the nurse take?
- A. Assign the UAP to provide care for another client and assume full care of the client.
- B. Remind the UAP to apply a fitted respirator mask before entering the client's room.
- C. Review the need for the UAP to wear a face mask while in close contact with the client.
- D. Instruct the UAP to notify the nurse of any changes in the client's respiratory status.
Correct Answer: C
Rationale: Reviewing the need for a face mask educates the UAP on droplet precautions necessary for pertussis.
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When triaging emergency room clients, which client should the nurse assess first?
- A. A child who has had a cold for two days and now is coughing up green sputum.
- B. A male adolescent who has been vomiting for the past 12 hours and describes himself as very weak.
- C. A female client with severe right lower abdominal pain who is febrile and vomiting.
- D. An elderly client with peripheral vascular disease who is complaining of severe leg pain when ambulating.
Correct Answer: C
Rationale: Severe abdominal pain with fever and vomiting suggests a potentially life-threatening condition like appendicitis, requiring immediate assessment.
When making assignments for residents of a long-term care facility who require assistance with feeding, which client should the charge nurse assign to the practical nurse (PN) rather than the unlicensed assistive personnel (UAP)?
- A. An elderly woman who refuses to eat most meals served.
- B. A disabled client who is learning to use adaptive equipment.
- C. A client who drools but swallows solids after many attempts.
- D. An older, edentulous client who has loose fitting dentures.
Correct Answer: A
Rationale: The client refusing meals requires a PN's assessment to address potential psychological or physiological issues.
The registered nurse (RN) is gathering supplies to assist a healthcare provider with a bedside thoracentesis when the emergency department (ED) nurse calls to report on a client with unstable angina who must be admitted immediately. A practical nurse (PN) and unlicensed assistive personnel (UAP) are available to the RN. How should the RN assign the necessary nursing actions?
- A. Assign the UAP to prepare the room while the PN obtains report on the new admission and the RN assists with the thoracentesis.
- B. Assign the UAP to assist with the thoracentesis while the PN goes to the ED to transport the client to the unit and the RN obtains report from the ED nurse.
- C. Assign the PN to assist with the thoracentesis while the RN obtains report and the UAP prepares the room for the new admission.
- D. Assign the PN to go to the ED to obtain report and transport the client while the UAP prepares the room and the RN assists with the thoracentesis.
Correct Answer: D
Rationale: The PN can handle report and transport, the UAP can prepare the room, and the RN is needed for the thoracentesis.
The charge nurse, working with one nurse, two practical nurses (PNs), a unit secretary, and two unlicensed assistive personnel (UAPs), is caring for 24 clients on a medical surgical unit. Which task is best for the charge nurse to assign to the PN?
- A. Transcription of the healthcare provider's treatment plan for a client transferred from a critical care unit.
- B. The subclavian dressing change on a client diagnosed with inflammatory bowel disease.
- C. The admission assessment of a client diagnosed with bacterial pneumonia.
- D. The insertion of a Foley catheter for a client diagnosed with septicemia.
Correct Answer: D
Rationale: Foley catheter insertion is within the PN's scope, a task-based procedure suitable for their training.
A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?
- A. Place an isolation cart outside of the room to initiate droplet precautions.
- B. Schedule bedside play time with the occupational therapist.
- C. Instruct the child's parents about the need for transmission precautions.
- D. Assign the child to a room close to the nurse's station.
Correct Answer: A
Rationale: Initiating droplet precautions with an isolation cart prevents mumps transmission, a priority for infection control.