Nokea
A confused client has been placed in physical restraints by order of the provider. Which task could be assigned to an unlicensed assistive personnel (UAP)?
- A. Assist the client with activities of daily living
- B. Monitor the clients physical safety
- C. Evaluate for basic comfort needs
- D. Document mental status and muscle strength
Correct Answer: A
Rationale: Assist the client with activities of daily living. The person to whom the activity is delegated must be capable of performing it. The UAP is capable of assisting clients with basic needs.
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The nurse is caring for a client with a complete heart block. The nurse should question which of the following orders?
- A. Administer lidocaine (Xylocaine) 50 mg IV push for PVCs in excess of six per minute.
- B. Administer atropine sulfate (Atropine) 0.05 mg IV for symptomatic bradycardia.
- C. Anticipate scheduling the client for a temporary pacemaker if the pulse continues to decrease.
- D. Mix 10 cc of 1:5,000 solution of isoproterenol (Isuprel) in 500 cc D5W for sustained bradycardia below 30.
Correct Answer: A
Rationale: Lidocaine suppresses ventricular activity, which could worsen complete heart block by reducing the ventricular escape rhythm. Options B, C, and D are appropriate: atropine increases heart rate, pacemakers treat persistent bradycardia, and isoproterenol supports severe bradycardia.
The nurse is caring for a neonate with an infection. The nurse would be MOST concerned if which of the following was observed?
- A. Heart rate of 150 bpm.
- B. Axillary temperature of 96°F (35.5°C).
- C. Weight increase of 4 oz.
- D. Respiratory rate of 65 at rest.
Correct Answer: D
Rationale: A respiratory rate of 65 at rest (normal 30–50) indicates tachypnea, suggesting sepsis or hypoxia. Options A, B, and C are less concerning.
The nurse is caring for a client who is postoperative day 1 after a prostatectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Urinary output of 200 mL/hour.
- D. Blood-tinged urine.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-prostatectomy requiring immediate evaluation. Options B, C, and D are expected: incision pain, high urinary output, and blood-tinged urine are normal on day 1.
A 3 year-old had a hip spica cast applied two hours ago. In order to facilitate drying, the nurse should
- A. Expose the cast to air and turn the child frequently
- B. Use a heat lamp to reduce the drying time
- C. Handle the cast with the abductor bar
- D. Turn the child as little as possible
Correct Answer: A
Rationale: Expose the cast to air and turn the child frequently. The child should be turned every two hours, with the cast's surface exposed to the air.
The nurse is teaching a client with a new diagnosis of epilepsy about lamotrigine (Lamictal). Which of the following statements by the client indicates a need for further teaching?
- A. I should report a rash to my doctor.
- B. I should take this medication at the same time each day.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if my seizures stop.
Correct Answer: D
Rationale: Stopping lamotrigine when seizures stop is incorrect, as epilepsy often requires lifelong treatment to prevent recurrence. Options A, B, and C are correct: rash may indicate Stevens-Johnson syndrome, consistent timing ensures steady levels, and alcohol increases sedation.