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A confused client has been placed in physical restraints by order of the healthcare provider. Which task could be assigned to an unlicensed assistive personnel (UAP)?
- A. Assist the client with activities of daily living
- B. Monitor the client's physical safety
- C. Evaluate for basic comfort needs
- D. Document mental status and muscle strength
Correct Answer: A
Rationale: The correct answer is A: 'Assist the client with activities of daily living.' Unlicensed assistive personnel (UAP) can help clients with activities of daily living, such as feeding, bathing, and dressing. This task is appropriate for UAP as it does not require professional judgment. Choices B, C, and D involve monitoring safety, evaluating needs, and documenting assessments, which require a licensed nurse's professional judgment and expertise.
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The community health nurse has been following the care for an adolescent with a history of morbid obesity, asthma, hypertension, and is 22 weeks into a pregnancy. Which of these lab reports sent to the clinic needs to be called to the teen's healthcare provider within the next hour?
- A. Hemoglobin 11 g/dL and calcium 6 mg/dL
- B. Magnesium 0.8 mEq/L and creatinine 3 mg/dL
- C. Blood urea nitrogen 28 mg/dL and glucose 225 mg/dL
- D. Hematocrit 33% and platelets 200,000
Correct Answer: B
Rationale: The correct answer is B. The low magnesium level and elevated creatinine suggest possible renal dysfunction, which is concerning, especially in a pregnant client with multiple risk factors such as morbid obesity, asthma, and hypertension. Immediate attention is needed to address the potential renal issues. The other choices do not indicate such urgent conditions. Hemoglobin and calcium levels in choice A are within acceptable ranges. Choice C shows elevated blood urea nitrogen and glucose levels, which may need monitoring but not immediate attention. Choice D's hematocrit and platelet levels are also within normal ranges and do not indicate an urgent issue.
A male client is brought to the emergency department as the result of a motorcycle accident. He was not wearing a helmet at the time of the accident and states that he has no intention of ever wearing one. Within the framework of the Transtheoretical Model (TTM), which response should the nurse provide?
- A. Wearing a helmet or not is certainly an individual decision.
- B. You should seriously consider wearing a helmet.
- C. Riding a motorcycle with a helmet increases your safety.
- D. I really think you don't have the facts about helmet use.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a large community disaster, a man states that the blast threw him out of a second-story window. Which action should the nurse implement first?
- A. Logroll the client to his side and assess for back injuries
- B. Perform a complete neurological assessment
- C. Open the client's airway immediately
- D. Place the nurse's hands around the client's neck to stabilize
Correct Answer: D
Rationale: In this situation, the nurse should first stabilize the client's neck to prevent potential spinal cord injuries. Logrolling the client or performing other assessments should only be done after ensuring spinal stabilization. Opening the airway immediately is important in cases of airway obstruction, but stabilizing the neck takes priority in this scenario. Performing a complete neurological assessment may delay immediate stabilization, which is crucial in suspected spinal injuries.
Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. This action by the nurse will assess
- A. Right ventricular pressure
- B. Left ventricular end-diastolic pressure
- C. Acid-Base balance
- D. Coronary artery stability
Correct Answer: B
Rationale: The correct answer is B: Left ventricular end-diastolic pressure. Pulmonary capillary wedge pressure is used to assess left ventricular end-diastolic pressure. This measurement provides valuable information on the filling pressure of the left ventricle. Choices A, C, and D are incorrect because monitoring pulmonary capillary wedge pressure does not directly assess right ventricular pressure, acid-base balance, or coronary artery stability.
A client with terminal cancer is experiencing severe pain. The nurse plans to implement which of the following pain management strategies?
- A. Administer analgesics on a fixed schedule
- B. Administer analgesics only when the client requests
- C. Use non-pharmacological methods only
- D. Increase the dose of analgesics when the client complains of pain
Correct Answer: A
Rationale: Administering analgesics on a fixed schedule is the most appropriate pain management strategy for a client with terminal cancer experiencing severe pain. This approach ensures consistent pain control and helps prevent breakthrough pain. Administering analgesics only when the client requests (Choice B) may lead to uncontrolled pain as the client may delay requesting medication until the pain becomes unbearable. Using non-pharmacological methods only (Choice C) may not provide adequate pain relief for a client experiencing severe pain. Increasing the dose of analgesics when the client complains of pain (Choice D) may result in inconsistent pain control and could lead to potential overdose or adverse effects.