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The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task would be most appropriate to assign to the LPN?
- A. Assist the UAP to learn to perform blood glucose checks.
- B. Monitor the potassium levels of a client with diarrhea.
- C. Administer a bulk laxative to a client diagnosed with constipation.
- D. Assess the abdomen of a client who has had complaints of pain.
Correct Answer: C
Rationale: Administering a laxative is within the LPN’s scope. Teaching UAPs, monitoring labs, and abdominal assessments require RN skills.
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The occupational health nurse has had five (5) clients come to the clinic complaining of abdominal cramping, nausea, and vomiting. Which information should the nurse teach the employees to decrease the spread of this condition?
- A. Teach the employees to cough into the sleeve.
- B. Teach the housekeepers to use an antibacterial soap.
- C. Teach the coworkers to get a hepatitis vaccine.
- D. Teach the employees to wash their hands frequently.
Correct Answer: D
Rationale: Frequent handwashing prevents the spread of gastroenteritis, likely causing these symptoms. Coughing into sleeves, antibacterial soap, and hepatitis vaccines are less relevant.
Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Evaluate the client’s intake and output.
- B. Take the client’s vital signs.
- C. Change the client’s intravenous solution.
- D. Assess the client’s perianal area.
Correct Answer: B
Rationale: Taking vital signs is within the UAP’s scope and supports monitoring in gastroenteritis. Evaluating intake/output, changing IV solutions, and assessing skin require RN skills.
The nurse is preparing the client for a fiberoptic colonoscopy for colon polyps. Which task can be delegated to the unlicensed assistive personnel (UAP)?
- A. Administer the polyethylene glycol electrolyte lavage solution.
- B. Explain to the client why this morning's breakfast is withheld.
- C. Start an intravenous site with 0.9% normal saline fluid.
- D. Administer a cleansing enema until the return is clear.
Correct Answer: D
Rationale: Administering a cleansing enema is within the UAP’s scope with training. Administering solutions, explaining procedures, and starting IVs require RN skills.
The client is diagnosed with gastroenteritis. Which laboratory data warrant immediate intervention by the nurse?
- A. A serum sodium level of 137 mEq/L.
- B. Arterial blood gases of pH 7.37, PaO2 95, PaCO2 43, HCO3 24.
- C. A serum potassium level of 3.3 mEq/L.
- D. A stool sample positive for fecal leukocytes.
Correct Answer: C
Rationale: A potassium level of 3.3 mEq/L indicates hypokalemia, risking arrhythmias, especially with diarrhea-related losses, requiring immediate intervention. Normal sodium, ABGs, and fecal leukocytes are less urgent.
Which gastrointestinal assessment data should the nurse expect to find when assessing the client in end-stage liver failure?
- A. Hypoalbuminemia and muscle wasting.
- B. Oligomenorrhea and decreased body hair.
- C. Clay-colored stools and hemorrhoids.
- D. Dyspnea and caput medusae.
Correct Answer: A
Rationale: Hypoalbuminemia and muscle wasting are common in end-stage liver failure due to impaired protein synthesis and malnutrition. Other options include less specific or unrelated findings.