Nokea
An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?
- A. How long have you been a UAP and what units you have worked on?
- B. What type of care do you give on the surgical unit and what ages of clients?
- C. What is your comfort level in caring for children and at what ages?
- D. Have you reviewed the list of expected skills you might need on this unit?
Correct Answer: D
Rationale: The UAP must be competent to accept the delegated task. Review of skills needed versus level of performance is the most efficient and effective way to determine this.
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The client with a left-sided weakness is to be discharged to home, where the client has an electrical bed. In preparation for discharge, the nurse assesses the client's ability to get out of bed independently- Which client actions indicate that further instruction is needed? Select all that apply.
- A. Places the bed in the lowest position
- B. Raises the head of the bed (HOB)
- C. Rolls onto the left side
- D. Pushes against the mattress with the weak elbow and stronger hand to rise to a sitting position
- E. Slides legs off the bed while pushing against the mattress to raise the body off the bed
- F. Once in a sitting position, sits at the edge of the bed for a few minutes before standing
Correct Answer: C,D
Rationale: C: Rolling onto the weaker left side is incorrect; the client should roll onto the stronger right side to maximize strength and stability. D: Using the weak elbow instead of the stronger elbow and hand to push off increases the risk of injury and instability.
The nurse is teaching parents measures to prevent scald and burn injuries to toddlers in the home. Due to toddlers' inquisitiveness, which recommendation by the nurse is most important?
- A. Turn pot handles toward the back of the stove.
- B. Use the microwave cautiously when cooking.
- C. Ensure that the smoke detector is on and working.
- D. Verify that the bathwater temperature is tepid.
Correct Answer: A
Rationale: Turning pot handles back prevents toddlers from grabbing them, addressing their curiosity and reducing scald risks.
A patient asks a nurse the following question. Exposure to TB can be identified best with which of the following procedures? Which of the following tests is the most definitive of TB?
- A. Chest x-ray
- B. Mantoux test
- C. Breath sounds examination
- D. Sputum culture for gram-negative bacteria
Correct Answer: B
Rationale: The Mantoux is the most accurate test to determine the presence of TB.
The nurse asks the NA to apply a mitten restraint for the client seated in the wheelchair next to the bed. Which observation by the nurse indicates that the NA needs further instructions on applying restraints?
- A. Restraint strap is tied to the bed frame next to the client.
- B. Restraint straps are secured using a half-bow slip knot.
- C. Two fingers can be inserted between the restraint and client's skin.
- D. Mesh portion of the mitten restraint is on the back of the hand.
Correct Answer: A
Rationale: Tying the restraint to the bed frame instead of the wheelchair frame risks injury if the wheelchair moves, indicating the NA needs further instruction.
The nurse is caring for a client with a newly applied long leg cast. Which of these actions should the nurse take first to prevent complications from the cast?
- A. Check pedal pulses bilaterally
- B. Elevate the leg on pillows
- C. Apply ice to the cast
- D. Instruct the client to wiggle toes hourly
Correct Answer: A
Rationale: Checking pedal pulses bilaterally is the first action to ensure adequate circulation and detect potential complications like compartment syndrome early.