Nokea
A nurse assigns a task to unlicensed assistive personnel. They state, 'We can’t do that.' Which is the best initial response for the nurse to make?
- A. Ask the unlicensed assistive personnel (UAP) the reason for the response
- B. Do the task, but discuss the UAP’s response with the manager
- C. Ignore the UAP’s initial response and repeat the assigned request
- D. Remind the UAP of the importance of teamwork
Correct Answer: A
Rationale: Asking the reason clarifies whether the refusal is due to scope, training, or other issues, promoting collaboration. Performing the task, ignoring, or lecturing avoids addressing the root cause.
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Exhibit 1
Medication administration record
Allergies: No known drug allergies
Medication Time
Insulin NPH: 75 units subcutaneously, twice daily 0800, 2000
Insulin lispro: sliding scale dosing, before meals and at bedtime 0800, 1130, 1730, 2100
Exhibit 2
Laboratory results and reference ranges
Sodium
136-145 mEq/L
(136-145 mmol/L) 141 mEq/L
(141 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 3.0 mEq/L
(3.0 mmol/L)
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L) 328 mg/dL
(18.2 mmol/L)
The nurse is preparing to administer medications scheduled for 0800 to a client with type 1 diabetes mellitus. After reviewing the client's morning laboratory test results, which of the following actions would be a priority for the nurse to take?
- A. Administer insulin lispro per protocol and insulin NPH
- B. Contact the client's health care provider
- C. Obtain a urine specimen to check for ketones
- D. Recheck the client's capillary blood glucose level
Correct Answer: B
Rationale: Abnormal lab results (e.g., severe hypo/hyperglycemia) require provider notification to adjust treatment. Administering insulin, checking ketones, or rechecking glucose are secondary without specific lab values.
The nurse is providing pin site care for an adult who is in skeletal traction. What should the nurse do when providing pin site care?
- A. Clean the pin site with alcohol
- B. Clean the pin site with hydrogen peroxide
- C. Clean the pin site with betadine and apply steroid ointment as ordered
- D. Clean the pin site with soap and water and apply antibiotic ointment as ordered
Correct Answer: D
Rationale: Pin site care involves cleaning with soap and water to prevent infection and applying antibiotic ointment as ordered to reduce bacterial growth, per standard protocols.
The nurse is to administer a tuberculin skin test. At what angle should the needle be inserted?
- A. A 10-degree angle
- B. A 30-degree angle
- C. A 60-degree angle
- D. A 90-degree angle
Correct Answer: A
Rationale: A 10-degree angle ensures intradermal injection for a tuberculin skin test, creating a wheal for accurate reading.
The nurse is discussing activities for parallel play with the parents of a 2-year-old child. Which of the following activities are appropriate suggestions for this type of play? Select all that apply.
- A. Digging in a sandbox
- B. Finger painting
- C. Playing a board game
- D. Playing soccer
- E. Pushing toy cars
Correct Answer: A,B,E
Rationale: Parallel play involves independent activities side-by-side, like digging, painting, or pushing cars. Board games and soccer require cooperative play, unsuitable for 2-year-olds.
A father suspected of child abuse tells the nurse, 'I shouldn't have grabbed him so hard. I had a really bad day at work and got all stressed out. The kid just wouldn't listen to me.' The defense mechanism used by the father is:
- A. Projection
- B. Displacement
- C. Undoing
- D. Compensation
Correct Answer: B
Rationale: Displacement involves redirecting emotions (stress from work) onto a less threatening target (child). Projection, undoing, and compensation do not apply.