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The licensed practical nurse (LPN) assigns the ambulation of a client to unlicensed assistive personnel (UAP). The LPN observes UAP placing the clients Foley bag on the IV pole at the level of the client's chest during client ambulation down the length of the hallway. What action should the LPN take initially?
- A. Immediately lower the bag and speak privately to unlicensed assistive personnel (UAP)
- B. Let UAP complete assigned tasks and speak to them at the end of the shift
- C. Praise UAP for encouraging the client to walk the entire hallway
- D. Speak with the nurse manager about the need for UAP inservice education
Correct Answer: A
Rationale: The Foley bag must be kept below bladder level to prevent urine backflow and infection risk. Immediate correction and private education ensure safety and learning without delay.
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The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?
- A. Neurotoxicity
- B. Hepatomegaly
- C. Nephrotoxicity
- D. Ototoxicity
Correct Answer: C
Rationale: Nephrotoxicity. Nephrotoxicity is a common side effect of calcium disodium edetate, in addition to lead poisoning in general.
The nurse is collecting data on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply.
- A. Bright red bleeding from anus
- B. Distended abdomen
- C. Has not passed stool (meconium)
- D. Nonbilious vomiting
- E. Refuses to feed
Correct Answer: B,C,D
Rationale: Hirschsprung disease causes intestinal obstruction, leading to a distended abdomen, failure to pass meconium, and nonbilious vomiting. Bright red bleeding suggests other causes (e.g., fissure). Feeding refusal is less specific.
The nurse and unlicensed assistive personnel (UAP) are caring for a client who is experiencing an acute episode of Ménière disease. Which action by the UAP would require the nurse to intervene?
- A. Assists the client to use the bedside commode
- B. Dims the lights in the client's room
- C. Places the bed in the lowest position with all side rails raised
- D. Turns off the television in the client's room
Correct Answer: C
Rationale: Raising all side rails during an acute Ménière's episode (vertigo, nausea) increases fall risk if the client attempts to climb over them. Other actions (assisting to commode, dimming lights, turning off TV) reduce stimulation and promote safety.
A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements?
- A. I will arrange for a conference with you and the UAP within the next week
- B. I can assure you that I will look into the matter
- C. I would like for you to approach the UAP about the problem the next time it occurs
- D. I will add this concern to the agenda for the next unit meeting
Correct Answer: C
Rationale: Helping staff manage conflict is part of the manager's role. It is appropriate to urge the nurse to confront the other staff member to work out problems without a manager's intervention when possible.
The charge nurse is observing the nurse apply a condom catheter for a client who is uncircumcised. The charge nurse should intervene if the nurse
- A. attaches the drainage tubing to a leg collection bag
- B. retracts the foreskin before applying the condom sheath
- C. assesses the condition of the penile skin prior to application
- D. leaves a 1- to 2-inch (2.5- to 5-cm) space at the tip of the condom
Correct Answer: B
Rationale: Retracting the foreskin before applying a condom catheter risks paraphimosis if not repositioned afterward, requiring intervention. Other actions are correct: attaching tubing, assessing skin, and leaving space prevent complications.