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The LPN/LVN has delegated basic hygienic care of several clients to a certified nursing assistant. Which action by the nurse will ensure that the clients receive the best care?
- A. Observe the nursing assistant during the performance of all care
- B. Ask the nursing assistant if there were any problems
- C. Check the nursing assistant's charting
- D. Observe the clients following administration of care by the nursing assistants
Correct Answer: D
Rationale: Observing clients post-care ensures care was performed correctly and identifies issues like skin integrity or comfort, ensuring quality. Constant observation, questioning, or charting checks are less direct.
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The nurse is caring for a client with a new colostomy.
- A. What is the most appropriate teaching point for a client with a new colostomy?
- B. Change the appliance every morning.
- C. Empty the pouch when it is one-third full.
- D. Use a mild soap to cleanse the peristomal skin.
- E. Apply a skin barrier only if irritation occurs.
Correct Answer: C
Rationale: Using a mild soap to cleanse the peristomal skin prevents irritation and maintains skin integrity. Changing the appliance daily is unnecessary, emptying at one-third full prevents leaks, and a skin barrier should be used routinely to protect the skin.
The nurse is teaching a client with a new diagnosis of epilepsy about lamotrigine (Lamictal). Which of the following statements by the client indicates a need for further teaching?
- A. I should report a rash to my doctor.
- B. I should take this medication at the same time each day.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if my seizures stop.
Correct Answer: D
Rationale: Stopping lamotrigine when seizures stop is incorrect, as epilepsy often requires lifelong treatment to prevent recurrence. Options A, B, and C are correct: rash may indicate Stevens-Johnson syndrome, consistent timing ensures steady levels, and alcohol increases sedation.
Which of the following observations best indicates to the nurse that a paraplegic client can adequately carry out activities of daily living at home after discharge?
- A. The client can shave himself and brush his teeth.
- B. The client can transfer himself into and out of his wheelchair.
- C. The client can maneuver his wheelchair without difficulty.
- D. The client can prepare his own well-balanced meals.
Correct Answer: B
Rationale: Transferring into and out of a wheelchair is essential for a paraplegic to perform ADLs independently, enabling mobility and access to other tasks. Shaving, maneuvering the wheelchair, and cooking are important but less critical if transfer ability is impaired.
The nurse is teaching a client with a new diagnosis of hyperlipidemia about atorvastatin (Lipitor). Which of the following statements by the client indicates a need for further teaching?
- A. I should report muscle pain to my doctor.
- B. I should take this medication at night.
- C. I should avoid drinking grapefruit juice.
- D. I should stop this medication if my cholesterol is normal.
Correct Answer: D
Rationale: Stopping atorvastatin when cholesterol is normal is incorrect, as hyperlipidemia often requires lifelong treatment to prevent cardiovascular events. Options A, B, and C are correct: muscle pain may indicate myopathy, nighttime dosing maximizes efficacy, and grapefruit juice increases drug levels.
A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to
- A. promote verbal and nonverbal communication with both the client and the interpreter
- B. speak only a few sentences at a time and then pause for a few moments
- C. plan that the encounter will take more time than if the client spoke English
- D. ask the client to speak slowly and to look at the person spoken to
Correct Answer: A
Rationale: The nurse should communicate with the client and the family, not with the interpreter. Culturally appropriate eye contact, gestures, and body language toward the client and family are important factors to enhance rapport and understanding. Maintain eye contact with both the client and interpreter to elicit feedback and read nonverbal cues.