Nokea
A nurse is planning to delegate client assignments to the assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?
- A. Adjust the flow rate of the client's oxygen tank
- B. Collect a urine sample
- C. Measure the client's pain level
- D. Monitor blood glucose levels
Correct Answer: B
Rationale: The correct answer is B: Collect a urine sample. Delegating this task to assistive personnel is appropriate as it falls within their scope of practice. Tasks like adjusting the flow rate of oxygen tanks, measuring pain levels, and monitoring blood glucose levels require clinical judgment and should be performed by a nurse. It is important for nurses to delegate tasks that align with the competencies of assistive personnel to ensure safe and effective patient care.
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A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching?
- A. Contact provider if the cord turns black
- B. Clean the base of the cord with hydrogen peroxide daily
- C. Keep the cord dry until it falls off
- D. The cord stump will fall off in ten days
Correct Answer: C
Rationale: The correct instruction to include in the teaching for cord care is to keep the cord dry until it falls off naturally. This helps prevent infection, as the cord typically falls off in 10-14 days, not within five days. Instructing the parent to contact the provider if the cord turns black (Choice A) is important to monitor for signs of infection. Cleaning the base of the cord with hydrogen peroxide daily (Choice B) is not recommended as it can delay healing. Stating that the cord stump will fall off in ten days (Choice D) provides a more accurate timeframe compared to the initial estimation of five days.
A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?
- A. Place the infant under a radiant warmer
- B. Move the probe site every 3 hours
- C. Heat the skin one minute prior to placing the probe
- D. Place the sensor on the index finger
Correct Answer: B
Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures more accurate monitoring of oxygen saturation. Placing the infant under a radiant warmer (choice A) is unnecessary and not related to pulse oximetry. Heating the skin before placing the probe (choice C) can lead to burns and is not recommended. Placing the sensor on the index finger (choice D) is not appropriate for continuous monitoring in infants.
A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?
- A. Client with surgical hypoparathyroidism and positive Trousseau's sign
- B. Client with Clostridium difficile and acute diarrhea
- C. Client with acute kidney injury and low urine specific gravity
- D. Client with oral cancer and reports a sore on his gums
Correct Answer: A
Rationale: The correct answer is A. A positive Trousseau's sign indicates hypocalcemia, which can lead to life-threatening complications like tetany or laryngospasm, making it the highest priority. Choices B, C, and D, while important, do not pose immediate life-threatening risks compared to the potential complications of severe hypocalcemia seen in a client with surgical hypoparathyroidism and a positive Trousseau's sign.
A nurse is receiving a report on four clients. Which of the following clients should the nurse assess first?
- A. A client who has an ileal conduit and mucus in the pouch
- B. Client with arteriovenous fistula with additional vibration palpated
- C. A client with chronic kidney disease and cloudy dialysate outflow
- D. A client with transurethral resection of the prostate with red-tinged urine
Correct Answer: C
Rationale: The nurse should assess the client with chronic kidney disease and cloudy dialysate outflow first because cloudy dialysate outflow suggests peritonitis, a serious complication of peritoneal dialysis that requires immediate intervention. Assessing and addressing peritonitis promptly is crucial to prevent further complications and ensure the client's safety. Choices A, B, and D present important findings that require attention but are not as urgent as peritonitis, which can quickly escalate and endanger the client's health.
A nurse is caring for a client who has DVT. Which of the following instructions should the nurse include in the plan of care?
- A. Limit the client's fluid intake to 1500 mL per day
- B. Massage the affected extremity to relieve pain
- C. Apply cold packs to the affected extremity
- D. Elevate the client's affected extremity when in bed
Correct Answer: D
Rationale: The correct instruction the nurse should include in the plan of care for a client with DVT is to elevate the affected extremity when in bed. Elevating the affected extremity helps improve venous return, reduces edema, alleviates discomfort, and promotes healing in clients with DVT. Limiting fluid intake can be detrimental as adequate hydration is important for circulation. Massaging the affected extremity can dislodge clots and worsen the condition. Applying cold packs can cause vasoconstriction, which is not recommended for DVT as it can impede blood flow further.