Nokea
A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with
- A. a Dopamine drip IV with vital signs monitored every 5 minutes
- B. a myocardial infarction that is free from pain and dysrhythmias
- C. a tracheotomy of 24 hours in some respiratory distress
- D. a pacemaker inserted this morning with intermittent capture
Correct Answer: B
Rationale: This client is the most stable with minimal risk of complications or instability. The nurse can utilize basic nursing skills to care for this client, making it suitable for a nurse from another unit.
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The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?
- A. Assign an RN to provide total care of the client
- B. Assign a nursing assistant to help the client with self-care activities
- C. Delegate complete care to an unlicensed assistive personnel
- D. Supervise a nursing assistant for skin care
Correct Answer: D
Rationale: Supervise a nursing assistant for skin care. The nursing assistant can inspect the skin while giving hygiene care, but the nurse should supervise skin care since assessment and analysis are needed.
The nurse is demonstrating the use of a fire extinguisher during a fire drill. Place the steps for using a fire extinguisher in the correct order.
- A. Squeeze the handle
- B. Sweep from side to side
- C. Pull the pin
- D. Aim at the base of the fire
Correct Answer: C,D,A,B
Rationale: The PASS technique is: Pull the pin (C), Aim at the base (D), Squeeze the handle (A), Sweep side to side (B).
Which of these clients is the priority for the nurse to report to the public health department within the next 24 hours?
- A. An infant with a positive culture of stool for Shigella
- B. An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
- C. A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii
- D. A middle-aged nurse with a history of varicella zoster virus and with crops of vesicles on an erythematous base that appear on the skin
Correct Answer: B
Rationale: Tuberculosis is a reportable disease because persons who had contact with the client must be traced and often must be treated with chemoprophylaxis for a designated time.
A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action?
- A. Discharge the client from home health care because of noncompliance
- B. Notify the provider of the client's failure to follow prescribed diet
- C. Discuss diet with the client to learn the reasons for not following the diet
- D. Make a referral to Meals-on-Wheels
Correct Answer: C
Rationale: Discuss diet with the client to learn the reasons for not following the diet. When new problems are identified, it is important for the nurse to collect accurate assessment data. Before reporting findings to the provider, it is best to have a complete understanding of the client's behavior and feelings as a basis for future teaching and intervention.
Which statement by the nurse is appropriate when directing an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?
- A. Have the client sit on the side of the bed for at least 2 minutes before helping him stand.
- B. If the client is dizzy on standing, ask him to take some deep breaths.
- C. Assist the client to the bathroom at least twice on this shift.
- D. After you assist him to the chair, let me know how he feels.
Correct Answer: A
Rationale: Give clear information to the UAP about what is expected for client safety. This instruction ensures the client is assessed for orthostatic hypotension before ambulating, reducing the risk of falls.