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A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP?
- A. A 76-year-old client with severe depression
- B. A middle-aged client with an obsessive compulsive disorder
- C. An adolescent with dehydration and anorexia
- D. A young adult who is a heroin addict in withdrawal with hallucinations
Correct Answer: B
Rationale: The UAP can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has minimal risk of instability of condition.
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Which of the following microorganisms are considered normal body flora?
- A. staphylococcus on the skin
- B. streptococcus in the nares
- C. candida albicans in the vagina
- D. pseudomonas in the blood
Correct Answer: A
Rationale: Of the choices given, only staphylococcus is considered a normal resident of the body.
A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that
- A. a referral is needed to the psychiatrist who is to provide the client with answers
- B. the client has a right to know about the prescribed medications
- C. such education is an independent decision of the individual nurse whether or not to teach clients about their medications
- D. clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects
Correct Answer: B
Rationale: The client has a right to know about the prescribed medications. Clients have a right to informed consent which includes information about medications, treatments, and diagnostic studies.
The nurse is caring for clients in a hospital setting. Which observations made by the nurse require intervention? Select all that apply.
- A. The client's infusion pump is noted to have a cut in the center of the cord.
- B. The client's bed is in the high position after a nursing assistant left the room.
- C. The client's battery-operated CD player does not have an agency inspection tag.
- D. The client's bed exit alarm is beeping, and another nurse just left the room.
- E. The client's bedside table is placed in front of the chair where the client is sitting.
Correct Answer: A,B,D
Rationale: A: A cut cord poses an electrical shock risk. B: A high bed increases fall risk. D: A beeping bed exit alarm indicates a potential fall risk requiring immediate response.
The experienced nurse is instructing the new nurse on client safety. Which statement made by the new nurse should the experienced nurse correct?
- A. "It is very important for school-aged children to be taught_statistics related to sports."
- B. "The leading causes of death in young adults are due to substance abuse and suicide."
- C. "Older adults especially should be asked whether they have ever accidentally fallen at home."
- D. "Preschooler activity should be monitored because falls are a major cause of nonfatal injuries."
Correct Answer: B
Rationale: The leading cause of death in young adults is motor vehicle accidents, not substance abuse and suicide, which requires correction.
The client makes the following statements to the home health nurse. Which statement requires the nurse to intervene immediately?
- A. "I can't lift pans from the back burners, but I can manage just fine by using the front burners of my stove."
- B. "I almost fell down the stairs, so I bought myself a pair of slippers with nonskid soles."
- C. "The grass near the sidewalk will be dead because my son insists on putting salt on the icy sidewalk."
- D. "My home is less costly to heat when I use my gas oven with the oven door open to heat just my living areas."
Correct Answer: D
Rationale: Using a gas oven for heating risks carbon monoxide poisoning, requiring immediate intervention to prevent a life-threatening situation.