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; medication administration and invasive procedures are not.
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Nurses'Notes
Day 1:
Client reports to clinic following trip to emergency department (ED) after a fall at home. Reports slipping
on a floor rug and hurting left ankle.
ray report taken in ED shows left lateral malleolus fracture. Removable boot immobilizer in place, using
a cane for assistance in ambulating
Boot immobilizer removed, left ankle with edema +2. Client reports pain as 6 on a scale of 0 to 10.
Client states they were prescribed pain medication by ED provider. Client lives alone.
Reports being "down to 1⁄2 pack of cigarettes, least 3 cups of coffee daily. States their mother was
always breaking something.
Day 3:
Bone Mineral Density DEXA scan -3.8 (-1 or above)
Based on the client's laboratory and diagnostic results, indicate which of the following provider
prescriptions the nurse should expect.
A nurse in a provider's clinic is assisting in the care of an older adult female client.
For each provider prescription click to specify if the provider prescription is expected or unexpected for
the client. There must be at least 1 selection in every row. There does not need to be a selection in every
column.
- A. Physical therapy for muscle-strengthening and balance-training
- B. Calcium 1500 mg po once daily on empty stomach
- C. Vitamin D supplement 2,500 units daily
- D. Home health evaluation of home safety
- E. Increase caffeine intake
- F. Increase daily sun exposure
Correct Answer: A, B, C, D
Rationale: A: Improves strength and reduces fall risk. B, C: Address osteoporosis (DEXA -3.8). D: Ensures safe environment.
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Avoid the use of facial gestures during the instructions.
- B. Determine the client's ability to use a communication board.
- C. Speak with a loud voice while providing the information.
- D. Provide the teaching without expecting the client to respond.
Correct Answer: B
Rationale: A communication board can aid clients with expressive aphasia in understanding and responding.
A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?
- A. Aren't you interested in learning how to perform this test?
- B. Let's talk about what you're thinking.
- C. I'll discuss this with your partner instead.
- D. Is this something you think you can do?
Correct Answer: B
Rationale: Exploring the client's thoughts addresses distractions and improves teaching effectiveness.
A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Request a prescription renewal from the provider every 36 hr.
- B. Check the client's range of motion every 6 hr.
- C. Secure the restraints with a square knot.
- D. Make sure two fingers fit under the restraints.
Correct Answer: D
Rationale: Ensuring two fingers fit prevents excessive tightness and circulation issues.
A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?
- A. Placing the restraint across the client's chest
- B. Applying the restraint over the client's gown
- C. Using a quick-release tie to secure the restraint
- D. Tying the restraint to the bed frame
Correct Answer: A
Rationale: Placing the restraint across the chest restricts breathing; it should be at the waist.