Nokea
A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
- A. Administering vaginal cream to a client who has a vaginal infection.
- B. Providing postmortem care for a client who has just died.
- C. Suctioning a tracheostomy for a client who has a recent head injury.
- D. Changing a peripheral IV dressing for a client who is postoperative.
Correct Answer: B
Rationale: Postmortem care is within the AP’s scope, involving basic care tasks.
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A nurse is caring for a postoperative male client in the surgical unit. Click to highlight the documentation in the client's medical record that requires further action by the nurse. Select all that apply
- A. Respiratory rate 10/min
- B. Pulse oximetry 88% on room air
- C. Blood pressure 99/46 mm Hg
- D. Morphine 10 mg administered subcutaneously
Correct Answer: A,B,D
Rationale: A: Low respiratory rate suggests opioid depression. B: Low SaO2 indicates hypoxemia. D: Morphine dose may need reassessment due to side effects.
A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position their hands?
- A. Place one hand over the other against the part of the gown covering their upper body.
- B. Clasp their hands together in a relaxed position behind their body at their waist.
- C. Keep their arms at the sides of their body with their hands in a relaxed position.
- D. Interlock their fingers and hold their hands away from their body above their waist.
Correct Answer: D
Rationale: Interlocking fingers above the waist prevents contamination of sterile gloves.
A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?
- A. Flex hips and knees when assisting the client to a standing position.
- B. Pivot on the foot farthest from the bed when assisting the client into the chair.
- C. Stand on the client's stronger side when moving the client into the chair.
- D. Raise the bed to waist level before moving the client.
Correct Answer: A
Rationale: Flexing hips and knees ensures stability and safety during the transfer process.
A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I'm glad to have the opportunity to choose what kind of care I receive while I still can.
- B. I can't change my mind about the care I will receive once I sign my living will.
- C. Once I fill out my living will, there will be a 1-month delay before it is legally binding.
- D. If I want life support, I'll need to sign a separate consent form first.
Correct Answer: A
Rationale: This reflects understanding that advance directives allow care choices while capable.
A home health nurse is reinforcing teaching about dietary needs with the child of a client. They state, 'I don't know what to do because they're not eating.' Which of the following responses should the nurse make?
- A. Tell me more about what happens at mealtime.
- B. They may need a feeding tube.
- C. Have you tried offering different foods?
- D. Let's discuss ways to encourage their appetite.
Correct Answer: A
Rationale: Exploring mealtime details provides insight into the client’s eating issues.