Nokea
In which situations would it be inappropriate for the nurse to delegate the patient's personal care to a CNA or UAP?
- A. A patient whose vital signs are unstable
- B. A patient who requires total care
- C. A patient whose capabilities to assist with personal care are unknown
- D. A patient who is from a different culture
- E. A patient who has a worsening skin condition
Correct Answer: A,C,E
Rationale: Delegation is inappropriate when vital signs are unstable, patient capabilities are unknown, or a worsening skin condition requires nursing assessment.
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The circulatory effect of venous return is accomplished by bathing:
- A. the back along the trapezius muscles.
- B. the extremities in a distal-to-proximal direction.
- C. the arm farthest away from you first, then the nearer arm.
- D. the extremities in a proximal-to-distal direction.
Correct Answer: B
Rationale: Bathing extremities distal-to-proximal promotes venous return by facilitating blood flow toward the heart.
You know a patient with diabetes needs more teaching about nail care when he says:
- A. My daughter can cut my toenails so they are rounded without any sharp edges.'
- B. I won't clip my toenails anymore. I will just file them.'
- C. Any reddened area on my feet can be a problem, so I will tell the doctor if I see any.'
- D. I don't want to risk even a small cut on my toes or feet.'
Correct Answer: A
Rationale: Diabetic patients should be cut straight across toenails to prevent ingrown nails and infections, not rounded.
The nurse is taking care of a patient who is a 78-year-old male who is bedridden. Which type of bath would be appropriate for the patient?
- A. Partial bath
- B. Complete bed bath
- C. Tub bath
- D. Bag bath
Correct Answer: B
Rationale: A bedridden patient requires a complete bed bath to ensure thorough hygiene, as they cannot participate in other bathing methods.
The staff nurse says that your patient refused her bath yesterday and really needs one today. The patient says she is too exhausted to have a bed bath and just wants to sleep. Your best response would be:
- A. That's fine. Sleep is more important than a bath, anyway.'
- B. I will do your bath first, then you will sleep better.'
- C. I have other patients to care for, so we need to do your bath now.'
- D. You rest now, and I will come back in about an hour to do your bath.'
Correct Answer: D
Rationale: Respecting the patient's need for rest while planning to provide care later balances patient comfort and hygiene needs.
A patient receiving a nasogastric tube feeding will have which common bed position?
- A. Flat
- B. Fowler's
- C. Semi-Fowler's
- D. Trendelenburg
Correct Answer: B,C
Rationale: Semi-Fowler's or Fowler's position prevents aspiration during nasogastric tube feeding by keeping the head elevated.