Nokea
A nurse at a long-term facility is providing a change-of-shift report to an oncoming nurse about an older adult client who has shingles. Which of the following information should the nurse include in the report?
- A. Where the client ate his breakfast
- B. The times for routine vital sign measurements
- C. The exact times the client had visitors
- D. The type of transmission-based precautions in place
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse is caring for a patient diagnosed with diabetes. Which task will the nurse assign to the nursing assistive personnel?
- A. Providing nail care
- B. Teaching foot care
- C. Making the patient's bed
- D. Determining aspiration risk
Correct Answer: C
Rationale: The correct answer is making the patient's bed. Delegating bed-making tasks to nursing assistive personnel is appropriate as it falls within their scope of practice and helps free up the nurse's time to focus on tasks that require their specialized skills and knowledge. Providing nail care and teaching foot care involve direct patient care and education, which should be performed by licensed nursing staff. Determining aspiration risk requires critical thinking and clinical judgment, making it a responsibility of the nurse.
Which nutritional assessment data should be collected to best reflect total muscle mass in an adolescent?
- A. Height in inches or centimeters.
- B. Weight in kilograms or pounds.
- C. Triceps skinfold thickness.
- D. Upper arm circumference.
Correct Answer: D
Rationale: The correct answer is 'Upper arm circumference.' Upper arm circumference is a better indicator of total muscle mass in adolescents compared to height, weight, or triceps skinfold thickness. Triceps skinfold thickness primarily reflects subcutaneous fat, while weight and height are not specific to muscle mass. Upper arm circumference directly measures the muscle mass in the upper arm and can provide a more accurate assessment in this context. Therefore, choices A, B, and C are incorrect because they do not directly reflect total muscle mass in adolescents.
The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver's license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next?
- A. Stand to the side of the patient's eye and observe the cornea.
- B. Conclude that the glasses were lost during the accident.
- C. Notify the ambulance personnel about the missing glasses.
- D. Ask the patient where the glasses are.
Correct Answer: A
Rationale: In this scenario, the nurse should stand to the side of the patient's eye and observe the cornea. This action is crucial in assessing whether the patient wears contact lenses, especially in unresponsive patients. Observing the cornea can provide valuable information about the patient's eye health and potential use of contact lenses. Choices B, C, and D are incorrect. Concluding that the glasses were lost during the accident is premature without proper assessment. Notifying ambulance personnel about the missing glasses may not be the immediate priority, and asking the unresponsive patient about the glasses would not yield useful information in this situation.
A client enters the emergency department unconscious via ambulance from the client's workplace. What document should be given priority to guide the direction of care for this client?
- A. The statement of client rights and the client self-determination act
- B. Orders written by the healthcare provider
- C. A notarized original copy of advance directives brought in by the partner
- D. The clinical pathway protocol of the agency and the emergency department
Correct Answer: C
Rationale: In the scenario described, when a client arrives unconscious, priority should be given to a notarized original copy of advance directives brought in by the partner. Advance directives are legal documents that specify a person's healthcare wishes and decision-making preferences in advance. These directives guide healthcare providers in delivering care according to the client's preferences when the client is unable to communicate. The statement of client rights and the client self-determination act (Choice A) are important but do not provide specific care instructions. Orders written by the healthcare provider (Choice B) may not reflect the client's wishes. Clinical pathway protocols (Choice D) are valuable but do not address the individualized care preferences of the client.
A nurse manager is preparing to review practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?
- A. Insert an implanted port
- B. Close a laceration with sutures
- C. Place an endotracheal tube
- D. Initiate an enteral feeding through a gastrostomy tube
Correct Answer: D
Rationale: The correct answer is D: Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes. Options A, B, and C involve procedures that typically fall within the scope of other healthcare professionals. Inserting an implanted port is often performed by specialized nurses or physicians, closing a laceration with sutures is usually done by healthcare providers with specific training in wound care, and placing an endotracheal tube is a procedure commonly carried out by anesthesiologists or respiratory therapists.