Nokea
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a postoperative transplant unit. Which task should the nurse delegate to the UAP?
- A. Assess the hourly outputs of the client who is post-kidney transplantation.
- B. Raise the head of the bed for a client who is post-liver transplantation.
- C. Monitor the serum blood studies of a client who has rejected an organ.
- D. Irrigate the nasogastric tube of the client who had a pancreas transplant.
Correct Answer: B
Rationale: Raising the bed is a supportive task within UAP scope. Assessing outputs, monitoring labs, or irrigating NG tubes requires nursing judgment.
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The client asks the nurse, 'When will the durable power of attorney for health care take effect?' On which scientific rationale would the nurse base the response?
- A. It goes into effect when the client needs someone to make financial decisions.
- B. It will be effective when the client is under general anesthesia during surgery.
- C. The client must say it is all right for it to become effective and enforced.
- D. It becomes valid only when the clients cannot make their own decisions.
Correct Answer: D
Rationale: A durable power of attorney for health care activates when the client is incapacitated, per legal standards. Financial decisions, anesthesia, or client permission are incorrect triggers.
The primary nurse caring for the client who died is crying with the family at the bedside. Which action should the charge nurse implement?
- A. Request the primary nurse to come out in the hall.
- B. Refer the nurse to the employee assistance program.
- C. Allow the nurse and family this time to grieve.
- D. Ask the chaplain to relieve the nurse at the bedside.
Correct Answer: C
Rationale: Allowing the nurse to grieve with the family supports emotional bonding, unless it impairs care. Removing, referring, or replacing the nurse may disrupt this moment.
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients in a pain clinic. Which intervention would be inappropriate to delegate to the UAP?
- A. Assist the client diagnosed with intractable pain to the bathroom.
- B. Elevate the head of the bed for a client diagnosed with back pain.
- C. Perform passive range of motion for a client who is bedfast.
- D. Monitor the potassium levels on a client about to receive medication.
Correct Answer: D
Rationale: Monitoring potassium levels requires nursing judgment, outside UAP scope. Assisting to bathroom, elevating bed, and range of motion are within UAP capabilities.
The female client in the oncology clinic tells the nurse she has a great deal of pain but does not like to take pain medication. Which action should the nurse implement first?
- A. Tell the client it is important for her to take her medication.
- B. Find out how the client has been dealing with the pain.
- C. Have the HCP tell the client to take the pain medications.
- D. Instruct the client not to worry-the pain will resolve itself.
Correct Answer: B
Rationale: Assessing coping strategies informs a tailored pain management plan, respecting client preferences. Forcing medication, HCP involvement, or dismissing pain is premature.
The hospice nurse is making the final visit to the wife whose husband died a little more than a year ago. The nurse realizes the husband's clothes are still in the closet and chest of drawers. Which action should the nurse implement first?
- A. Discuss what the wife is going to do with the clothes.
- B. Refer the wife to a grief recovery support group.
- C. Do not take any action because this is normal grieving.
- D. Remove the clothes from the house and dispose of them.
Correct Answer: C
Rationale: Keeping clothes is a normal part of grieving, requiring no immediate action. Discussing plans, referring to support, or removing clothes may rush or distress the widow.