Nokea
The charge nurse in a long-term memory care facility is making assignments for the Alzheimer unit. Which tasks may be delegated to experienced unlicensed assistive personnel? Select all that apply.
- A. Assisting clients with bathing and hair care
- B. Evaluating safety hazards in clients' rooms
- C. Monitoring clients for behavioral changes
- D. Placing bed alarms at night for clients at risk for wandering
- E. Reporting a client's swallowing difficulties during mealtime
Correct Answer: A,D,E
Rationale: Bathing/hair care (A), placing bed alarms (D), and reporting swallowing issues (E) are within UAP scope. Evaluating hazards (B) and monitoring behavior changes (C) require nursing judgment.
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A client with acquired immunodeficiency syndrome is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?
- A. Thoroughly cooking all foods
- B. Offering yogurt and buttermilk between meals
- C. Forcing fluids
- D. Providing small, frequent meals
Correct Answer: D
Rationale: Small, frequent meals are easier to digest and absorb, compensating for the limited absorptive capacity in wasting syndrome. Cooking foods thoroughly reduces infection risk but doesn't aid absorption. Yogurt and buttermilk may not be tolerated, and forcing fluids addresses hydration, not absorption.
A parent has numerous questions regarding normal growth and development of a 10 month-old infant. Which of the following parameters is of most concern to the nurse?
- A. 50% increase in birth weight
- B. Head circumference greater than chest
- C. Crying when the parents leave
- D. Able to stand up briefly in play pen
Correct Answer: A
Rationale: 50% increase in birth weight. Birth weight should double by 6 months, indicating potential growth issues that require further evaluation.
An 86-year-old client with diabetes and gastroparesis has had repeated hospitalizations for aspiration pneumonia following a stroke and is now hospitalized with altered level of consciousness. Which nursing action is most appropriate to decrease the client's risk for developing aspiration pneumonia?
- A. Assessing client's breath sounds every 2 hours
- B. Placing client in the side lying position in bed
- C. Titrating client's oxygen to maintain saturation 93%
- D. Turning and repositioning the client every 2 hours
Correct Answer: B
Rationale: The side-lying position (B) reduces aspiration risk by preventing reflux into the airway, especially in clients with altered consciousness. Assessing breath sounds (A), oxygen titration (C), and repositioning (D) are supportive but less effective for prevention.
The nurse is caring for a hospice client with advanced heart failure who is having trouble breathing. Which comfort intervention should the nurse implement first?
- A. Administer PRN albuterol by nebulizer
- B. Assist with guided imagery to relieve anxiety
- C. Elevate the head of the bed
- D. Give PRN sublingual morphine
Correct Answer: C
Rationale: Elevating the head of the bed (C) is the first non-pharmacologic intervention to ease breathing in heart failure by reducing pulmonary congestion. Albuterol (A) is for bronchospasm, imagery (B) is secondary, and morphine (D) is for severe distress.
The nurse is talking with a client who is scheduled for cardiac catheterization. Which of the following findings would be essential to follow up? Select all that apply.
- A. elevated serum C-reactive protein level
- B. previous allergic reaction to IV contrast
- C. prolonged PR interval on ECG
- D. received metformin today for type 2 diabetes mellitus
- E. elevated serum creatinine
Correct Answer: B,D,E
Rationale: Allergy to contrast (B), recent metformin use (D), and elevated creatinine (E) increase risks during cardiac catheterization (anaphylaxis, lactic acidosis, and renal injury). CRP (A) and PR interval (C) are less urgent.