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The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks should the nurse assign to the UAP?
- A. Obtain a tympanic temperature for a client who received naproxen one hour ago
- B. Record and empty a closed suction drain for a client recovering from a mastectomy
- C. Assist a client in picking out low-sodium foods on their lunch menu
- D. Transport a client receiving an infusion of dopamine to the intensive care unit
Correct Answer: A
Rationale: Obtaining a tympanic temperature (A) is a routine task within UAP scope. Recording drain output (B), dietary education (C), and transporting a client on dopamine (D) require nursing judgment or monitoring.
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The emergency department (ED) nurse is caring for a client brought in after being found walking around a neighborhood without shoes, confused and disoriented. The nurse should initially
- A. obtain vital signs.
- B. perform a mental status exam.
- C. attempt to locate the client’s family.
- D. request an order for a psychiatry consultation.
Correct Answer: A
Rationale: Obtaining vital signs (A) is the initial priority to assess for physiological instability (e.g., hypothermia, hypoglycemia) in a confused client. Mental status exam (B), family contact (C), and psychiatry consult (D) follow after ensuring medical stability.
The nurse is observing unlicensed assistive personnel (UAP) care for assigned clients. Which of the following actions by the UAP would require the nurse to intervene? Select all that apply.
- A. While helping the client with an active range of motion, the UAP flexes and extends the client's elbow.
- B. Obtains orthostatic blood pressure by having the client stand first.
- C. Places the cane on the unaffected side of a client who had a stroke.
- D. Provides a hot foot soak for a client with diabetes mellitus.
- E. Obtains a urine culture from an indwelling urinary catheter.
Correct Answer: B, D, E
Rationale: Standing first for orthostatic BP (B) risks syncope, hot foot soaks for diabetes (D) risk burns due to neuropathy, and urine culture collection (E) requires sterile technique, all inappropriate for UAPs. Range of motion (A) and cane placement (C) are correct UAP tasks.
A medication error has occurred in the medical ward. After a thorough investigation was performed, the nurse manager posts a memorandum regarding changes in medication administration to be implemented immediately. The nurses on the unit recognized this management style as:
- A. Autocratic
- B. Democratic
- C. Participative
- D. Laissez-faire
Correct Answer: A
Rationale: Posting a memorandum with immediate changes (A) reflects an autocratic management style, where the manager makes decisions unilaterally. Democratic (B) and participative (C) involve staff input, while laissez-faire (D) lacks direction.
The charge nurse is orientating a newly hired nurse to the charge nurse role. Which observation by the charge nurse requires follow-up? The newly hired nurse Select all that apply.
- A. requests the unlicensed assistive personnel (UAP) transport a client with respiratory distress to radiology.
- B. asks the licensed practical/vocational nurse (LPN/VN) to witness informed consent for a client scheduled for surgery.
- C. instructs the licensed practical/vocational nurse (LPN/VN) to review orders just written by the physician.
- D. assks the unlicensed assistive personnel (UAP) to transport blood specimens to the lab.
- E. assigns a client immediately postoperative from cardiac catheterization to a licensed practical/vocational nurse (LPN/VN).
Correct Answer: A, B
Rationale: Transporting a client with respiratory distress (A) by a UAP is unsafe, as they require monitoring. An LPN witnessing consent (B) is outside their scope; RNs or providers typically do this. Reviewing orders (C), transporting specimens (D), and assigning a stable post-catheterization client (E) are appropriate.
The nurse is triaging phone calls at the mental health clinic. Which client situation requires immediate follow-up? A client prescribed
- A. olanzapine reporting muscle stiffness and feeling hot.
- B. haloperidol reporting blurred vision and constipation.
- C. clozapine reporting occasional twitches of the mouth.
- D. aripiprazole reporting feeling very restless.
Correct Answer: A
Rationale: Muscle stiffness and feeling hot with olanzapine (A) suggest neuroleptic malignant syndrome, a life-threatening emergency requiring immediate follow-up. Blurred vision/constipation (B), mouth twitches (C), and restlessness (D) are less urgent side effects.