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A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
- A. Measure the intake and output of a client who has received furosemide.
- B. Assess the pain level of a client who has received acetaminophen.
- C. Reinforce teaching with a client about crutch-gait walking.
- D. Check a client's peripheral IV site for redness or swelling.
Correct Answer: A
Rationale: Measuring intake and output is within the AP’s scope and appropriate for delegation.
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A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?
- A. I understand that you decided not to receive blood products.
- B. You need to talk with your doctor about this.
- C. Not receiving blood will slow down your recovery.
- D. Why are you refusing to receive blood products?
Correct Answer: A
Rationale: Acknowledging the decision respects the client’s autonomy.
A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, 'I'm not going to take this medication because it makes me sick and dizzy.' Which of the following actions should the nurse take first?
- A. Document the refusal in the client's medical record.
- B. Return the medication to the medication cabinet.
- C. Inform the client of the potential consequences of their refusal.
- D. Notify the provider of the client's refusal.
Correct Answer: C
Rationale: Informing about consequences first respects autonomy and may encourage compliance.
A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?
- A. The client verbalizes regret about never marrying.
- B. The client is sedentary throughout most of the day.
- C. The client has no living family.
- D. The client has poorly fitting dentures.
Correct Answer: D
Rationale: Poorly fitting dentures can impair nutrition, posing an immediate health risk.
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps?
- A. Scrub the inside and outside of the inner cannula with a small brush.
- B. Wipe the inside of the inner cannula with a folded pipe cleaner.
- C. Cleanse the stoma site with 0.9% sodium chloride solution.
- D. Unlock and remove the inner cannula.
- E. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
Correct Answer: E,D,A,B,C
Rationale: E: Prepare solution. D: Remove cannula. A: Scrub cannula. B: Wipe cannula. C: Cleanse stoma maintains sterility.
A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?
- A. Turn off alarms on bedside monitoring equipment
- B. Avoid entering the client's room unless requested during the night.
- C. Conduct staff communications away from the client's room.
- D. Turn on the client's TV to distract from hallway noise.
Correct Answer: C
Rationale: Conducting staff communications away from the client's room reduces noise and promotes a restful environment.