Nokea
The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks would be appropriate for the nurse to assign to UAP? Select all that apply.
- A. Transport a client with an ankle fracture to radiology.
- B. Calculate and record a client's oral intake for the shift.
- C. Ambulate a client who is eight hours post-laparoscopic surgery.
- D. Assist a client with multiple sclerosis in performing oral care.
- E. Obtain a urine culture and sensitivity sample from an indwelling urethral catheter.
Correct Answer: A, C, D
Rationale: UAPs can transport stable clients (A), ambulate post-surgical clients (C), and assist with oral care (D). Calculating intake (B) requires clinical judgment, and obtaining a urine culture (E) involves sterile technique, both RN/LPN tasks.
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The nurse is performing a verbal hand-off report for a client admitted to the medical-surgical unit. Which essential information should the nurse include in the report?
- A. Discontinued medications
- B. Involuntary admission status
- C. Food and mealtime preferences
- D. The presence of family at the bedside
Correct Answer: A, B
Rationale: Discontinued medications (A) prevent administration errors, and involuntary admission status (B) ensures legal and safety compliance, both critical for safe care transitions per ISBAR standards. Food preferences (C) and family presence (D) are less essential for immediate care continuity.
The nurse in the emergency department (ED) is caring for an unconscious client who sustained a head injury following a motor vehicle crash. The health care provider (HCP) has ordered an emergency surgery. Which action should the nurse take regarding informed consent?
- A. obtain a court order for the surgical procedure in place of an informed consent
- B. search the client's belongings for any identification
- C. transport the client to the operating room for surgery immediately
- D. call the police to report the incident, identify the client, and locate the family
Correct Answer: C
Rationale: For an unconscious client requiring emergency surgery, implied consent applies, allowing immediate transport to the operating room (C) to save life or prevent harm. Court orders (A), searching belongings (B), or calling police (D) delay critical care and are not required for emergency consent.
The emergency department (ED) nurse is caring for a client who is 38 weeks pregnant and experiencing frequent contractions. The nurse observes a presenting part of the fetus during the exam. Which priority action should the nurse take?
- A. Assess the client's previous obstetric history
- B. Prepare for the delivery of the newborn
- C. Transport the client to the labor and delivery unit
- D. Time the frequency and duration of contractions
Correct Answer: B
Rationale: A visible presenting part (B) indicates imminent delivery, requiring immediate preparation for newborn delivery in the ED. Assessing history (A), transporting to labor and delivery (C), or timing contractions (D) delays critical action for an emergency birth.
The nurse is caring for a client who reports that another nurse hit them. The nurse should take which action?
- A. Inquire with the nurse if this incident occurred
- B. Assess the client for any prior episodes of abuse
- C. Determine if the client has any cognitive impairments
- D. Report the client's concern to the nursing supervisor
Correct Answer: D
Rationale: Reporting the allegation to the nursing supervisor (D) is the priority to ensure proper investigation and client safety, per facility policy. Inquiring directly (A), assessing prior abuse (B), or checking cognition (C) risks bias or delays formal action.
The nurse manager has observed a staff nurse return to work late multiple times following the lunch break. The nurse manager should take which initial action?
- A. Continue to observe the nurse's behavior
- B. Reprimand the nurse with written documentation
- C. Ask the nurse to check in before and after taking their lunch break
- D. Discuss with the nurse the consequences of being late
Correct Answer: C
Rationale: Asking the nurse to check in (C) is a proactive initial step to address tardiness while maintaining professionalism and gathering data. Continued observation (A) delays action, reprimand (B) is premature, and discussing consequences (D) escalates without initial intervention.