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Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the best initial approach?
- A. Consider a liquid supplement to increase calories
- B. Discuss consequences of an unbalanced diet with the child
- C. Provide fruit, vegetable and protein snacks
- D. Encourage the child to keep a daily log of foods eaten
Correct Answer: B
Rationale: Discuss consequences of an unbalanced diet with the child. It is important to educate the preadolescent as to appropriate diet, and the problems that might arise if diet is not adequate.
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A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)?
- A. Ask the client the degree of relief and document the client's response
- B. Decrease the set rate on the pump by 2 ml/minute
- C. Check the IV site for drainage and loose tape
- D. Assist the client with ambulation and a gown change with supervision
Correct Answer: D
Rationale: When directing the UAP, communicate clearly and specifically what the task is and what should be reported to the nurse. Implementation of routine tasks should be delegated since they do not require independent judgment.
The nurse is caring for a client with a history of bipolar disorder.
- A. Which client statement indicates a need for further teaching about lithium therapy?
- B. I’ll drink plenty of water every day.'
- C. I’ll have my blood levels checked regularly.'
- D. I can stop the medication if I feel better.'
- E. I’ll avoid eating foods high in sodium.'
Correct Answer: C
Rationale: Stating that the medication can be stopped when feeling better indicates a misunderstanding, as lithium requires consistent use to maintain therapeutic levels and prevent mood swings. Hydration, blood monitoring, and sodium awareness are correct.
A confused client has been placed in physical restraints by order of the provider. Which task could be assigned to an unlicensed assistive personnel (UAP)?
- A. Assist the client with activities of daily living
- B. Monitor the clients physical safety
- C. Evaluate for basic comfort needs
- D. Document mental status and muscle strength
Correct Answer: A
Rationale: Assist the client with activities of daily living. The person to whom the activity is delegated must be capable of performing it. The UAP is capable of assisting clients with basic needs.
Which client should receive a private room?
- A. A client with diabetes
- B. A client with Cushing's disease
- C. A client with Graves' disease
- D. A client with gastric ulcers
Correct Answer: D
Rationale: A client with gastric ulcers may have Helicobacter pylori infection, which can be contagious and requires isolation precautions. Clients with diabetes, Cushing's disease, or Graves' disease do not typically require private rooms unless they have a contagious condition.
An older woman hospitalized with a fractured left hip, placed in Buck's traction with a seven-pound weight while awaiting surgery.
Which of the following instructions for moving should be discussed by the nurse to encourage the patient to participate in her care?
- A. Pull up on the overhead trapeze while you push down on your right foot to lift your body.'
- B. With your right arm, grasp the bedside rail on the opposite side and pull yourself over gently.'
- C. I'll raise the head of the bed 45°, and then you lean forward and rotate your hips to the left.'
- D. Swing your right leg over your left leg, and turn from your waist down, keeping your legs straight.'
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-body must move as single, straight unit (2) turning or twisting from the waist down interferes with countertraction (3) prevents proper pull of weights (4) can't turn from side to side, can only move up and down