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During the shift report, the night charge nurse tells the day charge nurse that the night unlicensed assistive personnel (UAP) is totally incompetent. What is the best response for the day charge nurse to give?
- A. Encourage the night nurse to provide the UAP with additional training
- B. Indicate that it is the night nurse's job to deal with staff problems
- C. Remind the night nurse that the UAP is doing the best job the UAP can
- D. Suggest that the night nurse discuss concerns with the nurse manager
Correct Answer: D
Rationale: Suggesting discussion with the nurse manager (D) addresses the issue professionally. Encouraging training (A), deflecting responsibility (B), or defending the UAP (C) are less appropriate.
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A client continually repeats phrases that others have just said. The nurse recognizes this behavior as
- A. Autistic
- B. Echopraxis
- C. Echolalia
- D. Catatonic
Correct Answer: C
Rationale: Echolalia is repeating words or phrases heard before, often seen in certain psychiatric or developmental conditions.
Which of the following clients does the nurse identify as being at high risk for developing colorectal cancer? Select all that apply.
- A. Client who has a diet high in red meat and low in fiber
- B. Client who is morbidly obese
- C. Client with a 15-year history of ulcerative colitis
- D. Client with a 40-year history of cigarette smoking
- E. Client with a family history of colorectal cancer
Correct Answer: A, C, E
Rationale: High red meat/low fiber diet (A), ulcerative colitis (C), and family history (E) are established risk factors for colorectal cancer. Obesity (B) and smoking (D) have weaker associations.
The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?
- A. Place pillows under the knees
- B. Use elastic stockings continuously
- C. Encourage range of motion and ambulation
- D. Massage the legs twice daily
Correct Answer: C
Rationale: Encourage range of motion and ambulation. Mobility reduces the risk of deep vein thrombosis in the post-surgical client and the adult at risk due to other factors.
The practical nurse is collaborating with the registered nurse to form a care plan for a client diagnosed with placenta previa at 33 weeks gestation. Which of the following does the nurse anticipate being included in the plan of care? Select all that apply.
- A. Activity as tolerated
- B. Nonstress test 1 or 2 times per week
- C. Prepare for cesarean birth at any time
- D. Type and screen blood
- E. Vaginal examinations twice weekly
Correct Answer: B, C, D
Rationale: Nonstress tests (B), cesarean preparation (C), and type and screen (D) monitor and prepare for bleeding risks in placenta previa. Activity as tolerated (A) and vaginal exams (E) increase bleeding risk.
A client is to be discharged following the removal of a cataract on the right eye. The nurse should tell the client to:
- A. Wear the metal eye shield only during waking hours.
- B. Report any eye pain to the doctor immediately.
- C. Refrain from using a pillow under his head.
- D. Avoid wearing dark glasses inside.
Correct Answer: B
Rationale: Reporting eye pain immediately is critical as it may indicate complications like infection or increased intraocular pressure. The eye shield is typically worn at night or as directed. Using a pillow is not contraindicated. Dark glasses are often recommended to reduce glare.