Nokea
A nurse asks an unlicensed assistive personnel (UAP) to help admit a 22-year-old female client with ulcerative colitis. Which activity is appropriate for the nurse to assign the UAP?
- A. obtain a stool sample
- B. obtain abbreviated history of symptoms for the past 30 days
- C. instruct the client on the reason for undergoing a lower gastric X-ray exam
- D. obtain a sample of gastric contents from nasogastric tube
Correct Answer: A
Rationale: Obtaining a stool sample is within the UAP’s scope, as it is a non-invasive task. Other activities involve assessment or teaching, which require RN expertise.
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The school nurse is teaching a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates that further teaching is necessary?
- A. I should have a bottle of Ipecac for each of my children.
- B. I should induce vomiting if my child swallows lighter fluid.
- C. Giving my child water or milk may help dilute the poison.
- D. Proper storage is the key to poison prevention in the home.
Correct Answer: B
Rationale: vomiting contraindicated when child ingests hydrocarbons due to danger of aspiration
A client has immune thrombocytopenic purpura. The client's platelet count is 19,000. Which initial treatment does the nurse expect?
- A. Splenectomy
- B. Immunosuppressive therapy
- C. Observation only
- D. Platelet administration
Correct Answer: B
Rationale: For ITP with a platelet count of 19,000, immunosuppressive therapy (B), like corticosteroids, is typically initial to increase platelet production. Splenectomy (A) is later, observation (C) is risky, and platelets (D) are less effective.
The nurse is caring for a client with a small-bowel obstruction. A Salem sump nasogastric tube (NGT) is in place. Which finding by the nurse requires corrective action? Select all that apply.
- A. There is a sudden decrease in output.
- B. The NGT is set to low continuous suction.
- C. The NGT is set to medium intermittent suction.
- D. The patient is positioned in the semi-Fowler's position.
- E. The client dislodges the tube and the nurse replaces it, confirming placement by X-ray before use.
Correct Answer: A, C
Rationale: A sudden decrease in output may indicate blockage or displacement, requiring assessment. Medium intermittent suction is inappropriate for a Salem sump, which requires low continuous suction. Other actions are correct.
A diabetic client self-administers insulin four times daily. Which of the following statements by the client indicates the need for further education?
- A. I flush the used needles down the toilet.'
- B. I carry glucose tablets with me at all times.'
- C. I eat a little dessert occasionally.'
- D. I avoid wearing sandals.'
Correct Answer: A
Rationale: Flushing needles down the toilet (A) is unsafe and improper disposal; needles should be placed in a sharps container. Carrying glucose tablets (B), occasional desserts (C), and avoiding sandals (D) are appropriate for diabetes management.
A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority?
- A. Administer oxygen.
- B. Turn her to the right side.
- C. Provide adequate hydration.
- D. Start antibiotics.
Correct Answer: C
Rationale: adequate hydration is a priority for any client with sickle cell crisis