Nokea
The nurse asks the NA to apply a mitten restraint for the client seated in the wheelchair next to the bed. Which observation by the nurse indicates that the NA needs further instructions on applying restraints?
- A. Restraint strap is tied to the bed frame next to the client.
- B. Restraint straps are secured using a half-bow slip knot.
- C. Two fingers can be inserted between the restraint and client's skin.
- D. Mesh portion of the mitten restraint is on the back of the hand.
Correct Answer: A
Rationale: Tying the restraint to the bed frame instead of the wheelchair frame risks injury if the wheelchair moves, indicating the NA needs further instruction.
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The nurse teaching a client about hepatitis and its transmission should explain that one type of hepatitis does not produce a carrier state after its acute phase. Which type is it?
- A. hepatitis A
- B. hepatitis B
- C. hepatitis C
- D. hepatitis D
Correct Answer: A
Rationale: Hepatitis A does not produce a carrier state. It is transmitted via contaminated water or food via the oral-fecal route and is not blood borne.
A patient asks a nurse the following question. Exposure to TB can be identified best with which of the following procedures? Which of the following tests is the most definitive of TB?
- A. Chest x-ray
- B. Mantoux test
- C. Breath sounds examination
- D. Sputum culture for gram-negative bacteria
Correct Answer: B
Rationale: The Mantoux is the most accurate test to determine the presence of TB.
A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia (MRSA). What type of isolation is most appropriate for this client?
- A. Reverse
- B. Airborne
- C. Standard precautions
- D. Contact
Correct Answer: D
Rationale: Contact precautions or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected.
The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client
- A. has had a change in respiratory rate by an increase of 2 breaths
- B. has had a change in heart rate by an increase of 10 beats
- C. was minimally responsive to voice and touch
- D. has had a blood pressure change by a drop in 8 mmHg systolic
Correct Answer: C
Rationale: A change in level of consciousness indicates delirium related to acute illness. This would require the assessment of a nurse. The other changes could occur within the range of normal fluctuations.
An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?
- A. How long have you been a UAP and what units you have worked on?
- B. What type of care do you give on the surgical unit and what ages of clients?
- C. What is your comfort level in caring for children and at what ages?
- D. Have you reviewed the list of expected skills you might need on this unit?
Correct Answer: D
Rationale: The UAP must be competent to accept the delegated task. Review of skills needed versus level of performance is the most efficient and effective way to determine this.