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The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical unit. Which nursing task cannot be delegated to the UAP?
- A. Obtaining the intake and output on a client diagnosed with food poisoning.
- B. Performing a dressing change on the client with a chemical burn.
- C. Assisting a client who overdosed on morphine to the bedside commode.
- D. Help a client with carbon monoxide poisoning turn, cough, and deep breathe.
Correct Answer: B
Rationale: Dressing changes on chemical burns require assessment and sterile technique, a nursing task. Intake/output, ambulation, and turning are delegable to UAPs.
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The triage nurse is working in the emergency department. Which client should be assessed first?
- A. The 10-year-old child whose dad thinks the child’s leg is broken.
- B. The 45-year-old male who is diaphoretic and clutching his chest.
- C. The 58-year-old female complaining of a headache and seeing spots.
- D. The 25-year-old male who cut his hand with a hunting knife.
Correct Answer: B
Rationale: Chest pain with diaphoresis suggests acute myocardial infarction, a life-threatening emergency requiring immediate assessment. Fractures, headaches, and cuts are less urgent.
The nurse is providing discharge teaching for the client with intermaxillary wiring to repair a fractured mandible. Which statement by the client indicates teaching has been effective?
- A. Iced alcoholic drinks may be consumed by using a straw.
- B. Only one (1) food item should be consumed at one (1) time.
- C. Carbonated sodas should be limited to two (2) daily.
- D. Teeth can be brushed after tenderness and edema subside.
Correct Answer: D
Rationale: Brushing teeth after swelling subsides maintains oral hygiene safely. Alcohol, single food items, and soda limits are incorrect or unnecessary.
Which signs/symptoms should the nurse assess in the client who has been exposed to the anthrax bacillus via the skin?
- A. A scabby, clear fluid-filled vesicle.
- B. Edema, pruritus, and a 2-mm ulcerated vesicle.
- C. Irregular brownish-pink spots around the hairline.
- D. Tiny purple spots flush with the surface of the skin.
Correct Answer: B
Rationale: Cutaneous anthrax presents with edema, pruritus, and a small ulcerated vesicle that becomes necrotic. Scabby vesicles, brownish-pink spots, and purple spots are not typical.
The nurse working in an outpatient clinic is caring for a client who is experiencing epistaxis. Which intervention should the nurse implement first?
- A. Take the client’s blood pressure in both arms.
- B. Hold the nose with thumb and finger for 15 minutes.
- C. Have the client sit with the head tilted back and hold a tissue.
- D. Prepare to administer silver nitrate, a cauterizing agent, with a packing applicator.
Correct Answer: B
Rationale: Holding the nose for 15 minutes stops bleeding, the first intervention for epistaxis. BP, head tilting back (risks aspiration), and cauterization are secondary.
The client has ingested the remaining amount of a bottle of analgesic medication. The medication comes 500 mg per capsule. Two (2) doses of two (2) capsules each have been used by another member of the family. The bottle originally had 250 capsules. How many mg of medication did the client take?
Correct Answer: 123000
Rationale: Total capsules: 250. Used: 2 doses * 2 capsules = 4 capsules. Remaining: 250 - 4 = 246 capsules. Total mg: 246 * 500 mg = 123,000 mg.