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The home health aide caring for a homebound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?
- A. Listen for the presence of bowel sounds.
- B. Administer a prescribed dose of a laxative.
- C. Teach the client about foods high in fiber.
- D. Assist the client to drink warm prune juice.
Correct Answer: D
Rationale: Assisting with warm prune juice is a safe, simple task within the aide's scope to relieve constipation.
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A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse?
- A. The client post triple coronary bypass four days ago who has serosanguinous drainage in one chest tube.
- B. The client admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 195 mg/dL (10.8 mmol/L).
- C. The client with an ileal conduit created two days ago with a scant amount of blood in the drainage pouch.
- D. The client with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90%.
Correct Answer: D
Rationale: The pneumothorax client with low oxygen saturation is at risk of respiratory failure, requiring immediate assessment.
The charge nurse needs to determine if an additional nurse should be called to help staff the unit for the next shift. Which information is most important for the charge nurse to consider when making this decision?
- A. The number of clients leaving the unit for diagnostic tests.
- B. The acuity level of the clients on the unit.
- C. The physician's plans to perform procedures on the unit.
- D. The skill level of the personnel staffing the unit.
Correct Answer: B
Rationale: Client acuity determines the intensity of care needed, critical for staffing decisions.
A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first?
- A. Provide the UAP with the infection control policy.
- B. Offer to assist the UAP with the collection of the specimen.
- C. Determine the UAP's knowledge about HIV transmission.
- D. Demonstrate the proper use of personal protective equipment.
Correct Answer: C
Rationale: Determining the UAP's knowledge about HIV transmission is the first action to address their fear, identify misconceptions, and provide targeted education.
A client is admitted with shortness of breath and hemoptysis. After several tests, the healthcare provider informs the client that the medical diagnosis is stage 4 breast cancer. The client tells the nurse about the decision not to inform the family about the diagnosis. Which intervention should the nurse implement?
- A. Explain that the family has a right to know of potential health problems.
- B. Advise the client to weigh all possible outcomes prior to the decision.
- C. Suggest to the family the value of genetic screening.
- D. Notify the health department of the client's condition.
Correct Answer: B
Rationale: Advising the client to weigh outcomes supports their autonomy while encouraging informed decision-making.
The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?
- A. Review the medication transcription with the nurse.
- B. Evaluate the client for symptoms of a drug interaction.
- C. Report the medication error to the nursing supervisor.
- D. Inform the pharmacist who dispensed the medication.
Correct Answer: C
Rationale: Reporting the error ensures proper documentation and follow-up for client safety.