Nokea
A nurse is working with an unlicensed assistive personnel (UAP) to perform a bed bath on a client. The nurse notes the smell of alcohol on the UAP's breath. Which is the priority nursing action?
- A. Work closely with the UAP during the shift and observe for any signs of impairment.
- B. Complete the bed bath without comment. The unit is already short one staff member.
- C. Offer chewing gum to the UAP. Since she does not give medications, she can do her job as she does not appear impaired.
- D. Call for another nurse to complete the bath and immediately report the UAP to the charge nurse or unit manager.
Correct Answer: D
Rationale: The smell of alcohol suggests potential impairment, which poses a safety risk to clients. Reporting to the charge nurse ensures client safety and follows protocol. Options A, B, and C fail to address the potential risk adequately.
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The school nurse is monitoring the diet of a child with cystic fibrosis. Which type of diet would the family be advised to follow?
- A. low calorie, high fiber
- B. low fiber, low fat
- C. low sodium, gluten free
- D. high fat, high calorie
Correct Answer: D
Rationale: High-fat, high-calorie diets support nutritional needs in cystic fibrosis due to malabsorption.
The nurse is caring for a client who is post-op day 1 for a coronary artery bypass graft (CABG). The nurse knows that continuity of care for this client is ensured by doing which of the following? Select all that apply.
- A. using standardized handoff reports
- B. knowing how to perform a chart check
- C. following up on outstanding lab reports and incomplete orders
- D. knowing the proper procedures to transfer clients to another floor
Correct Answer: A,B,C,D
Rationale: Standardized handoffs, chart checks, following up on labs/orders, and proper transfer procedures all ensure continuity of care.
A charge nurse is preparing client care assignments for the upcoming shift. A client who underwent a laminectomy is scheduled to return from the recovery care unit. Which staff member should receive this client?
- A. graduate nurse with 3 months of experience
- B. RN with 1 year of experience
- C. certified nursing assistant with 5 years of experience
- D. charge nurse with 2 years of experience
Correct Answer: B
Rationale: An RN with 1 year of experience has sufficient skills for post-laminectomy care. A CNA lacks the scope, and a graduate nurse may need more experience.
An external weather disaster has flooded the emergency department with several new clients. Which client should the nurse see first?
- A. the client complaining of chest pain and nausea who is diaphoretic
- B. the client with a simple fracture of the radius from a fall on a staircase
- C. the client complaining of slight redness and itching at the IV site in his hand
- D. the client presenting with a sprained ankle from a tree branch falling on him
Correct Answer: A
Rationale: Chest pain, nausea, and diaphoresis suggest a potential myocardial infarction, a life-threatening condition requiring immediate attention. Options B, C, and D describe less urgent conditions.
Nurses are expected to understand the principles of triage when caring for multiple clients. The ICU charge nurse is reviewing assignments. Based on the principles of triage, to which client would the charge nurse give priority for treatment? Select all that apply.
- A. a client on a ventilator who has an alarm sounding
- B. a client who has just returned from an open appendectomy
- C. a client ready to transfer to the floor after the nurse calls report
- D. a client who has been talking with family and is now unresponsive
- E. a client receiving a new antibiotic who complains of tingling in the mouth
Correct Answer: A,D,E
Rationale: A ventilator alarm, unresponsiveness, and tingling (possible anaphylaxis) indicate immediate threats to life, requiring priority in triage.