Nokea
All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which duties are appropriate for the licensed practical nurse to delegate to unlicensed assistive personnel to promote client safety? Select all that apply.
- A. Educate newly admitted client on the importance of using the call light for assistance
- B. Place the bedside commode as close to the bed as possible
- C. Remind client to change position slowly
- D. Report observations of changes in client’s condition immediately
- E. Report whether client is using correct gait and balance while ambulating with walker
Correct Answer: B,C,D
Rationale: UAP can place commodes (B), remind about slow position changes (C), report condition changes (D), and observe gait (E). Education (A) requires nursing judgment, unsuitable for delegation.
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A client returns from the operating room after a right orchiectomy. For the immediate post-operative period the nursing priority would be to
- A. maintain fluid and electrolyte balance
- B. manage post-operative pain
- C. ambulate the client within 1 hour of surgery
- D. control bladder spasms
Correct Answer: B
Rationale: Due to the location of the incision, pain management is the priority. Bladder spasms are more related to prostate surgery.
The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women?
- A. Low tar cigarettes are less harmful during pregnancy
- B. There is a relationship between smoking and low birth weight
- C. The placenta serves as a barrier to nicotine
- D. Moderate smoking is effective in weight control
Correct Answer: B
Rationale: There is a relationship between smoking and low birth weight. Smoking reduces placental blood flow, contributing to fetal hypoxia and low birth weight.
An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents’ primary language is Vietnamese, and their English proficiency is very limited. What is the best approach for the nurse to use when reinforcing instructions to the parents on how to care for the child at home?
- A. Demonstrate the procedure using simple English phrases
- B. Give the parents written instructions with picture illustrations
- C. Tell the parents to have a friend or relative come in to translate
- D. Use an interpreter via the telephone interpretation service
Correct Answer: D
Rationale: A professional interpreter (D) ensures accurate communication, critical for colostomy care. Simple English (A) risks misunderstanding, pictures (B) are insufficient alone, and informal translators (C) may lack medical accuracy.
The nurse is caring for a client with hepatic encephalopathy who is receiving lactulose. Which of the following findings would indicate that the medication has been effective?
- A. Improved mental status
- B. Looser consistency of stool
- C. Reduced abdominal distension
- D. Increased serum potassium level
Correct Answer: A
Rationale: Lactulose is used in hepatic encephalopathy to reduce ammonia levels by promoting its excretion through the stool. Improved mental status (A) indicates reduced ammonia toxicity, directly reflecting the medication's therapeutic effect. Looser stools (B) and reduced abdominal distension (C) are expected effects of lactulose but are secondary to the primary goal of ammonia reduction. Increased serum potassium (D) is incorrect, as lactulose does not directly affect potassium levels.
A client with a history of heart disease takes prophylactic aspirin daily. The nurse should monitor which of the following to prevent aspirin toxicity?
- A. Serum potassium
- B. Protein intake
- C. Lactose tolerance
- D. Serum albumin
Correct Answer: D
Rationale: Serum albumin. When highly protein-bound drugs are administered to patients with low serum albumin (protein) levels, excess free (unbound) drug can cause exaggerated and dangerous effects.