Nokea
A nurse on a med-surg unit is teaching a newly licensed nurse about tasks to delegate to APs. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. An AP may take orthostatic blood pressure measurements from a client who reports dizziness.
- B. An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids.
- C. An AP may perform a central line dressing change for a client who is ready for discharge.
- D. An AP may ambulate a client who had a stroke 2 days ago.
Correct Answer: D
Rationale: The correct answer is D. Delegating the task of ambulating a client who had a stroke 2 days ago to an AP is appropriate. This task falls within the scope of practice for an AP and can help promote mobility and prevent complications. Choices A, B, and C involve more complex nursing assessments or procedures that require a higher level of training and expertise. Taking orthostatic blood pressure measurements, monitoring a peripheral IV insertion site, and performing a central line dressing change should be tasks performed by licensed nurses to ensure proper assessment and management of the client's condition.
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A healthcare professional is caring for a client who has a prescription for a vest restraint. Which of the following actions should the healthcare professional take?
- A. Tie the restraint with a quick-release knot.
- B. Use a slipknot to secure the restraint.
- C. Ensure the restraint is tightly secured.
- D. Attach the restraint to the bed frame.
Correct Answer: A
Rationale: The correct action for the healthcare professional to take when applying a vest restraint is to tie it with a quick-release knot. A quick-release knot allows for easy and rapid removal in case of an emergency, ensuring the safety of the client. Using a slipknot (Choice B) is not recommended as it may not provide quick release in emergencies. Ensuring the restraint is tightly secured (Choice C) can be dangerous as it can restrict circulation or cause discomfort. Attaching the restraint to the bed frame (Choice D) is inappropriate and can lead to potential harm or injury to the client.
The nurse is caring for a client who is post-operative following a cholecystectomy. Which assessment finding would require immediate intervention?
- A. Absent bowel sounds
- B. Pain level of 8/10
- C. Temperature of 100.4°F
- D. Saturated abdominal dressing
Correct Answer: D
Rationale: A saturated abdominal dressing may indicate active bleeding or other complications that require immediate intervention, such as ensuring hemostasis and preventing further complications. Absent bowel sounds are common in the immediate post-operative period and may not require immediate intervention unless accompanied by other symptoms. A pain level of 8/10 can be managed with appropriate pain medication and is not typically considered an immediate priority unless other indications suggest complications. A temperature of 100.4°F is slightly elevated but may not be a cause for immediate concern unless it is associated with other signs of infection or distress that would warrant urgent attention.
During a complete bed bath for a client, after removing the gown and placing a bath blanket over the body, which of the following areas should the nurse wash first?
- A. Face
- B. Feet
- C. Chest
- D. Arms
Correct Answer: A
Rationale: When performing a complete bed bath, it is essential to wash the face first. Washing the face initially helps to maintain the client's privacy and comfort. Additionally, starting with the face prevents re-contamination of already cleaned areas. Washing the feet first (Choice B) is not ideal as it can lead to potential contamination of the upper body parts. Starting with the chest (Choice C) or arms (Choice D) is not recommended due to the risk of water dripping onto the client's face, causing discomfort and compromising privacy.
During preoperative education, a nurse should assess a client's readiness to learn before a mastectomy. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
- A. "I don't want my spouse to see my incision."
- B. "Will you give me pain medicine after the surgery?"
- C. "Can you tell me about how long the surgery will take?"
- D. "My roommate listens to everything I say."
Correct Answer: C
Rationale: The correct answer is C. Asking about the duration of the surgery indicates readiness to learn about the procedure. This question shows that the client is actively seeking information about the surgical process, demonstrating readiness to learn. Choices A, B, and D reflect concerns, specific requests, or statements unrelated to the learning process. They do not directly indicate readiness to absorb information about the upcoming mastectomy.
During a home safety assessment for a client receiving supplemental oxygen, which observation should the nurse identify as proper safety protocol?
- A. The client uses non-acetone nail polish remover.
- B. The client uses an electric razor for shaving.
- C. The client cleans their oxygen equipment weekly.
- D. The client uses wool blankets.
Correct Answer: A
Rationale: The correct answer is A. Using non-acetone nail polish remover is crucial for clients on supplemental oxygen as acetone is flammable and poses a safety risk. Acetone can react with oxygen, increasing the fire hazard. Choices B, C, and D are incorrect. Electric razors can generate sparks, which are dangerous near oxygen due to the risk of ignition. While cleaning oxygen equipment is important, the type of nail polish remover used is more critical for immediate safety. Wool blankets can create static electricity, increasing the risk of fire around oxygen due to its flammability.