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A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?
- A. To observe the type and amount of nasogastric tube drainage
- B. Monitor the client for nausea or other complications
- C. Irrigate the nasogastric tube with the ordered irrigant
- D. Perform nostril and mouth care
Correct Answer: D
Rationale: Skin care around a nasogastric tube is a routine task that is appropriate for UAPs. The other tasks involve assessment or advanced skills that require a licensed nurse.
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What does client and family communication and education concerning restraints do?
- A. confuses both groups more
- B. helps with coping and stress levels
- C. encourages cooperation with the client and family
- D. puts the responsibility on the client and family, not the nurse
Correct Answer: C
Rationale: Cooperation is more likely if the client and family understand the purpose of and expected gains from restraints. Well-meaning family members might release restraints if their purpose is not clear.
Which of these actions by the nurse best prevents medication errors when administering medications to a client?
- A. Checking the client's wristband before giving medications
- B. Using two forms of client identification before administering medication
- C. Administering medications at the exact time they are ordered
- D. Verifying the medication order with another nurse
Correct Answer: B
Rationale: Using two forms of client identification (e.g., name and medical record number) is the best practice to prevent medication errors by ensuring the right client receives the medication.
A nurse taking a patient's history realizes the patient is complaining of SOB and weakness in the lower extremities. The patient has a history of hyperlipidemia, and hypertension. Which of the following may be occurring?
- A. The patient is developing CHF
- B. The patient may be having a MI
- C. The patient may be developing COPD
- D. The patient may be having an onset of PVD
Correct Answer: B
Rationale: Myocardial infarction may be associated with SOB and muscle weakness.
The nurse is evaluating the performance of the UAP. The nurse should provide feedback to the UAP about which unsafe action?
- A. Cleanses and returns a wheelchair to a storage area after being used by the client.
- B. Ties the bedridden client's wrist restraint ties to the bed frame using a quick-release knot.
- C. Grasps the cord to unplug an intravenous infusion pump for the client's transport to x-ray.
- D. Turns on a bed exit alarm for the confused client who was talking incoherently to the UAP.
Correct Answer: C
Rationale: Grasping the cord to unplug the pump can damage the cord, increasing the risk of electrical shock, requiring feedback to the UAP.
The charge nurse is observing nursing staff. In which activity illustrated should the charge nurse intervene because it places the nurse most at risk for back injury?
- A. intervene_1.PNG
- B. intervene_2.PNG
- C. intervene_3.PNG
- D. intervene_4.PNG
Correct Answer: D
Rationale: Bending and twisting the torso, as described in option D, poses the highest risk for back injury due to improper body mechanics, even with a transfer belt. The client's potential to grab the nurse's shoulder or arm increases the risk by destabilizing the nurse's stance.