Nokea
A client with influenza is admitted to the medical unit. The nurse observes an unlicensed assistive personnel (UAP) preparing to enter the client's room to take vital signs and assist with personal care. The UAP has applied gloves and a gown. Which action should the nurse take?
- A. Review the need for the UAP to wear a face mask while in close contact with the client.
- B. Remind the UAP to apply a fitted respirator mask before entering the client's room.
- C. Assign the UAP to provide care for another client and assume full care of the client.
- D. Instruct the UAP to notify the nurse of any changes in the client's respiratory status.
Correct Answer: A
Rationale: Reviewing the need for a face mask ensures proper droplet precautions for influenza, completing the UAP's PPE. A respirator is unnecessary, reassigning the UAP is impractical, and monitoring respiratory changes is secondary to infection control.
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The nurse determines that an IV vesicant chemotherapy infusion is infiltrated. In responding to this finding, which task can the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Record the patient's pulse volume distal to the IV site every hour.
- B. Reapply cold compresses to the site of the extravasation every hour.
- C. Dispose of the IV tubing after the infusion is discontinued.
- D. Teach the patient about the need to keep the extremity elevated.
Correct Answer: C
Rationale: Disposing of IV tubing is a routine task within the UAP's scope. Recording pulse volume, reapplying compresses, and teaching require clinical judgment, which are RN responsibilities.
A male client is admitted with difficulty breathing related to a recent diagnosis of metastatic lung cancer. He tells the nurse that he does not want to be hooked up to any machines. His vital signs are heart rate 120 beats/minute, blood pressure 98/50 mm Hg, respirations 30 breaths/minute, and oxygen saturation 88%. Which action should the nurse take?
- A. Obtain the client's legal records for power of attorney.
- B. Give analgesic medications as needed (PRN).
- C. Discontinue the intravenous infusion.
- D. Ask the palliative care team to speak with the client.
Correct Answer: D
Rationale: Consulting palliative care respects the client's wish to avoid machines and provides holistic end-of-life support. Power of attorney, analgesics, and IV discontinuation are secondary or inappropriate.
Which client requires the most immediate intervention by the nurse?
- A. An older adult receiving enteral feedings via feeding tube who has a temperature of 100.6°F (38.1°C).
- B. A client with acute kidney injury who is somnolent and does not respond to verbal commands.
- C. A young adult who experienced heat stroke and is receiving a normal saline intravenous (IV) fluid bolus.
- D. A pregnant client with hyperemesis gravidarum who is receiving an infusion of Ringer's Lactate.
Correct Answer: B
Rationale: The client with acute kidney injury and unresponsiveness likely has uremic encephalopathy, a life-threatening condition requiring immediate intervention. The other clients' conditions are less urgent as they are receiving appropriate treatments.
When triaging emergency room clients, which client should the nurse assess first?
- A. A male adolescent who has been vomiting for the past 12 hours and describes himself as very weak.
- B. A female client with severe right lower abdominal pain who is febrile and vomiting.
- C. An elderly client with peripheral vascular disease who is complaining of severe leg pain when ambulating.
- D. A child who has had a cold for two days and now is coughing up green sputum.
Correct Answer: B
Rationale: Severe right lower abdominal pain with fever and vomiting suggests appendicitis, a surgical emergency requiring immediate assessment. Vomiting, leg pain, and green sputum are less urgent conditions.
A client with tachycardia and hypotension presents to the emergency department (ED) reporting severe vomiting and diarrhea for three days. Which action is most important for the nurse to implement?
- A. Monitor for impending signs of shock.
- B. Initiate enteric precaution procedures.
- C. Reduce light, noise and temperature.
- D. Encourage electrolyte supplements.
Correct Answer: A
Rationale: Monitoring for signs of shock is critical due to the client's dehydration and fluid volume deficit, which could lead to organ failure. Enteric precautions, environmental adjustments, and electrolyte supplements are important but secondary to preventing life-threatening shock.