Nokea
It is the first day on the job for the newly hired unlicensed assistive personnel (UAP). Which of these illustrate appropriate assignment instructions for the licensed practical nurse (LPN) to give the UAP? Select all that apply.
- A. Elevate the right leg on two pillows.'
- B. Measure client for compression stockings.'
- C. Please let me know what the urine looks like.'
- D. Tell me what the client eats at lunch.'
- E. Verify wrist restraints are on correctly.'
Correct Answer: A,C,D
Rationale: Appropriate UAP tasks include elevating a leg , observing urine appearance , and reporting food intake . Measuring for stockings and verifying restraints require nursing judgment.
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A 72-year-old woman is being treated for pneumonia. Physician's orders include an antibiotic, oxygen PRN for O2 saturation less than 90, and pulse oximetry every 4 hours. The nurse obtains a pulse oximetry reading of 82% on room air. What is the best action for the nurse to take?
- A. Report the finding to the physician
- B. Report the finding to the registered nurse to get instructions
- C. Start supplemental oxygen
- D. Start oxygen and repeat the pulse oximetry in 20 minutes
Correct Answer: C
Rationale: An O2 saturation of 82% requires immediate supplemental oxygen per orders to correct hypoxia, the priority action.
The client is scheduled for a paracentesis. What should the nurse expect to do prior to the procedure?
- A. Insert an indwelling catheter
- B. Have the client void
- C. Keep the client NPO
- D. Administer an enema
Correct Answer: B
Rationale: Having the client void before paracentesis prevents bladder puncture during the procedure. Catheter insertion, NPO status, or enemas are not typically required.
The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be most appropriate?
- A. Fluid restriction 1000cc per day
- B. Ambulate in hallway 4 times a day
- C. Administer analgesic therapy as ordered
- D. Encourage increased caloric intake
Correct Answer: C
Rationale: Administer analgesic therapy as ordered. Pain management is critical during a sickle cell crisis.
The nurse has attended a staff education program about narcissistic personality disorder (NPD). The nurse should understand that clients with NPD
- A. experience a fear of abandonment and have a fragile self-esteem
- B. may require medication to manage hallucinations
- C. demonstrate magical thinking and feelings of depersonalization
- D. experience episodes of acute anxiety
Correct Answer: A
Rationale: Clients with NPD typically have a fragile self-esteem masked by grandiosity and may fear abandonment . Hallucinations are not characteristic, magical thinking aligns more with schizotypal personality disorder, and acute anxiety is less specific.
The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet
- A. High in carbohydrates and proteins
- B. Low in carbohydrates and proteins
- C. High in carbohydrates, low in proteins
- D. Low in carbohydrates, high in proteins
Correct Answer: A
Rationale: High in carbohydrates and proteins. This diet supports energy needs and compensates for malabsorption in cystic fibrosis.