Nokea
A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention?
- A. UAP has attached a bed alarm to the client's gown and bed
- B. UAP has been making hourly rounds on the client
- C. UAP has lowered the bed and raised all 4 side rails
- D. UAP has placed a fall risk ID bracelet on the client's wrist
Correct Answer: C
Rationale: Raising all four side rails is a restraint and can increase fall risk if the client attempts to climb over them. It also violates standards of care unless specifically prescribed.
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An adult who has hepatitis A asks the nurse why her skin is yellow. The nurse should include which information when replying?
- A. The diseased liver is not able to convert bilirubin into bile, so bilirubin pigments stay in the bloodstream and cause the skin and sclera to turn yellow.
- B. The virus that causes hepatitis A leaves a yellow pigment in the bloodstream.
- C. The affected liver cells produce more bilirubin than usual, causing the skin to turn yellow.
- D. The body is trying to get rid of fecal waste products through the skin.
Correct Answer: A
Rationale: Hepatitis A impairs liver function, reducing bilirubin conjugation and excretion, leading to its accumulation in the blood, causing jaundice. The virus does not produce pigment, nor does the liver overproduce bilirubin or excrete waste through skin.
The nurse prepares to reinforce teaching for a client with latent tuberculosis who is prescribed oral isoniazid. Which instructions should the nurse include? Select all that apply.
- A. Avoid drinking alcohol
- B. Expect body fluids to change color to red
- C. Report yellowing of skin or sclera
- D. Report numbness and tingling of extremities
- E. Take with aluminum hydroxide to prevent gastric irritation
Correct Answer: A,C,D
Rationale: Avoiding alcohol (A), reporting jaundice (C), and reporting neuropathy (D) address isoniazid's risks of hepatotoxicity and peripheral neuropathy.
The unlicensed assistive personnel notifies the charge nurse that the client is reporting feeling short of breath. What should the charge nurse do first?
- A. Activate a rapid response team
- B. Ask the unlicensed assistive personnel to take vital signs and report back
- C. Direct the client's primary nurse to examine the client
- D. Personally go and auscultate the client's lungs
Correct Answer: C
Rationale: Directing the primary nurse to assess the client ensures a timely, qualified evaluation of shortness of breath, a potentially serious symptom.
A 14-year old with leukemia tells the nurse, 'All I really want to eat is frozen yogurt.' The nurse should:
- A. Explain the importance of eating a balanced diet
- B. Ask the dietician to talk with the client to find out which foods he prefers
- C. Ask the kitchen to send the yogurt
- D. Document the client's refusal to eat the diet as ordered
Correct Answer: C
Rationale: Providing the requested yogurt respects the client's preferences and encourages intake, which is critical in leukemia patients who may have reduced appetite.
The nurse is caring for a client with liver cirrhosis. Which of the following assessment findings would warrant immediate follow up?
- A. Black, tarry stool
- B. Bright red-streaked stool
- C. Light gray clay-colored stool
- D. Small, dry, rocky stool
Correct Answer: A
Rationale: Black, tarry stool (melena) indicates upper gastrointestinal bleeding, a serious complication in cirrhosis due to portal hypertension or varices, requiring immediate intervention.