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After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond by saying
- A. He has a lot of problems. You need to have patience with him.
- B. I will talk with him and try to figure out what to do.
- C. He may be scared and taking it out on you. Let's talk to figure out what to do.
- D. Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day.
Correct Answer: C
Rationale: This response explains the client's behavior without belittling the UAP's feelings. The UAP is encouraged to contribute to the plan of care to help solve the problem.
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Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)?
- A. Be with a client who self-administers insulin
- B. Cleanse and dress a small decubitus ulcer
- C. Monitor a client's response to passive range of motion exercises
- D. Apply and care for a client's rectal pouch
Correct Answer: D
Rationale: The RN may delegate the application and care of rectal pouches to a UAP. This is an uncomplicated, routine task that does not require clinical judgment or advanced skills.
Which of these comments by a client would indicate the need for further teaching regarding safety with warfarin (Coumadin)?
- A. I need to stop the medication 3 days before my dental appointment.'
- B. I will report any bruising or bleeding to my doctor.'
- C. I plan to eat more green leafy vegetables this week.'
- D. I will check with my doctor before taking any new medication.'
Correct Answer: C
Rationale: Green leafy vegetables are high in vitamin K, which can counteract the anticoagulant effects of warfarin, requiring further teaching to ensure safe dietary practices.
The client that the nurse is ambulating becomes dizzy and feels faint. Place the nurse's actions in the correct order to prevent the client from falling.
- A. Support and ease the client to the floor by sliding the client down the forward leg
- B. Call for help
- C. Bend at the knees and pull the client toward the forward leg
- D. Assess the client for injuries
- E. Protect the client's head from hitting objects on the floor
- F. Assume a broad stance with the stronger leg somewhat behind the other leg
Correct Answer: B,F,C,A,E,D
Rationale: The sequence ensures safety: call for help (B), establish a stable stance (F), lower the client safely (C, A), protect the head (E), and assess injuries (D).
The nurse should perform which intervention when a client is restrained?
- A. Remove the restraints and provide skin care hourly.
- B. Document the condition of the client's skin every 3 hours.
- C. Assess the restraint every 30 minutes.
- D. Tie the restraint to the side rails.
Correct Answer: C
Rationale: The minimum standard is to visually assess the restraint every 30 minutes. Documentation is typically performed per a checklist or flow sheet. The ends of the restraint are tied to a part of the bed that allows for position changes without unfastening them.
A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action?
- A. Discharge the client from home health care because of noncompliance
- B. Notify the provider of the client's failure to follow prescribed diet
- C. Discuss diet with the client to learn the reasons for not following the diet
- D. Make a referral to Meals-on-Wheels
Correct Answer: C
Rationale: Discuss diet with the client to learn the reasons for not following the diet. When new problems are identified, it is important for the nurse to collect accurate assessment data. Before reporting findings to the provider, it is best to have a complete understanding of the client's behavior and feelings as a basis for future teaching and intervention.