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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?
- A. Providing oral care for an unconscious client with a tracheostomy
- B. Assisting a client with diabetes in monitoring blood glucose levels
- C. Assisting a client with a history of falls with ambulation in the hallway
- D. Assisting a client with wound dressing changes for a surgical incision
Correct Answer: C
Rationale: Assisting with ambulation for a client with fall risk (C) is within the UAP’s scope, ensuring safety with supervision. Oral care for tracheostomy (A), glucose monitoring (B), and dressing changes (D) require clinical judgment or sterility, inappropriate for UAPs.
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The nurse is caring for a group of assigned clients. The nurse should immediately follow up on the client who
- A. has a closed-chest drainage system and has redness at the insertion site.
- B. is receiving treatment for ulcerative colitis and has had three bloody stools in the past hour.
- C. is being treated for a concussion and reports a headache rated as 4 on a scale of 0 (no pain) to 10 (severe pain).
- D. is being treated for an ischemic stroke and has a blood pressure of 100/58 mm Hg.
Correct Answer: D
Rationale: Hypotension (100/58 mm Hg) in ischemic stroke (D) suggests hemodynamic instability, risking cerebral perfusion and requiring immediate follow-up. Redness at chest tube site (A), bloody stools in ulcerative colitis (B), and mild headache in concussion (C) are concerning but less immediately life-threatening.
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 is caring for a client diagnosed with multiple myeloma. The nurse reviews the client's lab values and notes a serum calcium level of 14 mg/dL (3.5 mmol/L) [9-10.5 mg/dL]. What is the priority action the nurse should take?
- A. Notify the primary healthcare provider (PHCP)
- B. Document the finding
- C. Continue to monitor the client
- D. Remove the client from the telemetry monitor
Correct Answer: A
Rationale: Hypercalcemia of 14 mg/dL in multiple myeloma (A) is a medical emergency risking cardiac arrhythmias, requiring immediate PHCP notification. Documentation (B) and monitoring (C) are secondary, and removing telemetry (D) is inappropriate, as monitoring is needed.
A registered nurse (RN) and a licensed practical/vocational nurse (LPN/VN) are working together in a psychiatric ward. Which of the following clients can the RN assign to the LPN/VN? A client
- A. taking amitriptyline who is currently grinding their jaw and grimacing
- B. with dementia who is currently confused and disoriented
- C. with bipolar disorder with a lithium level of 2.0 mEq/L [0.6-1.2 mEq/L]
- D. with a history of chronic alcoholism currently experiencing delirium tremens
Correct Answer: B
Rationale: A client with dementia who is confused (B) is stable and suitable for LPN care, focusing on safety and routine tasks. Jaw grinding on amitriptyline (A), toxic lithium level (C), and delirium tremens (D) require RN assessment due to potential toxicity or instability.
The nurse preceptor educates the new graduate nurse that which of the following statements made by an elderly client indicate the achievement of ego integrity? Select all that apply.
- A. I wish I could change some things in my past.'
- B. I’d like to volunteer at the youth center a few days a week.'
- C. I’m thinking of helping people learn to read and write.'
- D. I signed up for an art class at the senior center.'
- E. I never achieved the career title I should have'
Correct Answer: B, C, D
Rationale: Volunteering (B), teaching literacy (C), and joining an art class (D) reflect ego integrity, showing life acceptance and purpose per Erikson’s theory. Regret over past (A) or career (E) indicates despair, not integrity.