Nokea
A nurse taking a patient's history realizes the patient is complaining of SOB and weakness in the lower extremities. The patient has a history of hyperlipidemia, and hypertension. Which of the following may be occurring?
- A. The patient is developing CHF
- B. The patient may be having a MI
- C. The patient may be developing COPD
- D. The patient may be having an onset of PVD
Correct Answer: B
Rationale: Myocardial infarction may be associated with SOB and muscle weakness.
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The nurse is evaluating the performance of the UAP. The nurse should provide feedback to the UAP about which unsafe action?
- A. Cleanses and returns a wheelchair to a storage area after being used by the client.
- B. Ties the bedridden client's wrist restraint ties to the bed frame using a quick-release knot.
- C. Grasps the cord to unplug an intravenous infusion pump for the client's transport to x-ray.
- D. Turns on a bed exit alarm for the confused client who was talking incoherently to the UAP.
Correct Answer: C
Rationale: Grasping the cord to unplug the pump can damage the cord, increasing the risk of electrical shock, requiring feedback to the UAP.
How many feet should separate the nurse and the source when extinguishing a small, wastebasket fire with an appropriate extinguisher?
- A. 1 foot
- B. 2 feet
- C. 4 feet
- D. 6 feet
Correct Answer: D
Rationale: The nurse should stand about 6 feet from the source of the fire. Getting closer might put the nurse in danger.
A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?
- A. To observe the type and amount of nasogastric tube drainage
- B. Monitor the client for nausea or other complications
- C. Irrigate the nasogastric tube with the ordered irrigant
- D. Perform nostril and mouth care
Correct Answer: D
Rationale: Skin care around a nasogastric tube is a routine task that is appropriate for UAPs. The other tasks involve assessment or advanced skills that require a licensed nurse.
The charge nurse is observing nursing staff. In which activity illustrated should the charge nurse intervene because it places the nurse most at risk for back injury?
- A. intervene_1.PNG
- B. intervene_2.PNG
- C. intervene_3.PNG
- D. intervene_4.PNG
Correct Answer: D
Rationale: Bending and twisting the torso, as described in option D, poses the highest risk for back injury due to improper body mechanics, even with a transfer belt. The client's potential to grab the nurse's shoulder or arm increases the risk by destabilizing the nurse's stance.
The charge nurse is planning assignments on a medical unit. Which client should be assigned to the practical nurse (PN)?
- A. Test a stool specimen for occult blood
- B. Assist with the ambulation of a client with a chest tube system
- C. Irrigate and redress a leg wound
- D. Admit a client from the emergency room
Correct Answer: C
Rationale: The PN is a licensed provider and can perform this complex task. Irrigating and redressing a leg wound requires clinical skills appropriate for a PN, whereas the other tasks are either simpler or require an RN.