Nokea
A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)?
- A. Ask the client the degree of relief and document the client's response
- B. Decrease the set rate on the pump by 2 ml/minute
- C. Check the IV site for drainage and loose tape
- D. Assist the client with ambulation and a gown change with supervision
Correct Answer: D
Rationale: When directing the UAP, communicate clearly and specifically what the task is and what should be reported to the nurse. Implementation of routine tasks should be delegated since they do not require independent judgment.
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A client is admitted for a series of Test s to verify the diagnosis of Cushing's syndrome.
Which of the following assessment findings, if observed by the nurse, would support this diagnosis?
- A. Buffalo hump, hyperglycemia, and hypernatremia.
- B. Nervousness, tachycardia, and intolerance to heat.
- C. Lethargy, weight gain, and intolerance to cold.
- D. Irritability, moon face, and dry skin.
Correct Answer: A
Rationale: Strategy: Think about each answer choice and how it relates to Cushing's syndrome. (1) correct-Cushing's syndrome is characteristic of these assessments, as are weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections (2) symptoms of hyperthyroidism (3) symptoms of hypothyroidism (myxedema) (4) symptoms of hypoparathyroidism
A woman has returned from surgery after a right mastectomy with an IV of 0.9% NaCl infusing at 100 cc/hour into her left forearm. Several hours later, the IV infiltrates. The nurse is supervising a student nurse preparing to insert a new peripheral intravenous catheter. The nurse would intervene in which of the following situations?
- A. The student nurse selects a site where the veins are soft and elastic.
- B. The student nurse selects a site on the distal portion of the left arm.
- C. The student nurse selects a site close to the joint to provide for stability.
- D. The student nurse holds the skin taut to stabilize the vein.
Correct Answer: C
Rationale: inappropriate; movement in area could cause displacement
A comatose patient who is incontinent.
The nurse should intervene if which of the following actions is noted?
- A. The nurse assistant answers the phone while wearing gloves.
- B. The nursing assistant log rolls the patient to provide back care.
- C. The nursing assistant places an incontinence pad under the patient.
- D. The nursing assistant positions the patient on the left side, head elevated.
Correct Answer: A
Rationale: Strategy: 'Nurse should intervene' indicates that you are looking for an incorrect action. (1) correct-contaminated gloves should be removed before answering the phone (2) correct way to roll a patient to maintain proper alignment (3) appropriate to use incontinence pad for this patient (4) appropriate position to prevent aspiration and protect the airway
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD).
- A. Which arterial blood gas result is expected in a client with chronic COPD?
- B. pH 7.40, PaCO2 40 mmHg, PaO2 90 mmHg.
- C. pH 7.32, PaCO2 50 mmHg, PaO2 70 mmHg.
- D. pH 7.45, PaCO2 30 mmHg, PaO2 95 mmHg.
- E. pH 7.30, PaCO2 35 mmHg, PaO2 85 mmHg.
Correct Answer: B
Rationale: Chronic COPD causes CO2 retention, leading to a compensated respiratory acidosis with low pH (7.32), high PaCO2 (50 mmHg), and low PaO2 (70 mmHg) due to impaired gas exchange. Normal or acute values are incorrect.
A 76-year-old man receiving isoniazid (INH) 200 mg every day for 6 months.
The nurse would be MOST concerned if the client made which of the following statements?
- A. I have blurred vision at times.'
- B. My legs and knees hurt.'
- C. My hands and feet tingle.'
- D. I think I had a migraine yesterday.'
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to Isoniazid. (1) infrequent side effect of the medication (2) not a side effect of the medication (3) correct-may cause peripheral neuropathy indicated by tingling, may also see nausea (4) not a side effect of the medication