Nokea
The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP?
- A. Report signs of redness overlying a joint
- B. Monitor the client's response to ambulatory activity
- C. Encouragement for the independence in self-care
- D. Assist the client to transfer from a bed to a chair
Correct Answer: B
Rationale: Monitor the client's response to interventions requires assessment, a task to be performed by an RN.
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The nurse is caring for a client with tuberculosis who is on airborne isolation precautions. The nurse can delegate which tasks to experienced unlicensed assistive personnel? Select all that apply.
- A. Alert the x-ray department about maintaining airborne isolation precautions
- B. Explain to the client why the client must wear a mask during transport to another department
- C. Post signs for airborne isolation precautions on the client's door and stock necessary equipment
- D. Remind visitors to wear a respirator mask and keep the door closed while in the client's room
- E. Talk with the family about the reasons for airborne isolation precautions in the client
Correct Answer: C, D
Rationale: Posting signs and stocking equipment (C) and reminding visitors about precautions (D) are within UAP scope. Alerting departments (A), explaining to the client (B), and educating family (E) require nursing judgment.
An adult client in an acute care facility says to the nurse, 'I hope this hospital doesn't have student doctors and nurses. I do not want a student taking care of me.' The nurse's response should be based on which of the following understandings?
- A. When a client signs permission for treatment in a hospital, this includes treatment by medical and nursing students.
- B. The client has the right to know if the hospital is affiliated with a medical school and to refuse care by students.
- C. The client may sign a special form that says he refuses to be cared for by medical or nursing students.
- D. The client should be informed if any caregivers are students, but the client does not have the right to refuse to be cared for by students.
Correct Answer: B
Rationale: Clients have the right to know about student involvement and refuse student care, respecting autonomy. Consent doesn't inherently include students, and special forms or mandatory acceptance are incorrect.
The nurse is making assignments for the day's care. Which assignment should not be given to the nursing assistant?
- A. Emptying the Foley catheter bag
- B. Administering a Fleet's enema
- C. Measuring the oral intake
- D. Feeding a client with depression
Correct Answer: B
Rationale: Administering an enema requires nursing judgment and is outside a nursing assistant's scope. Other tasks are appropriate for a nursing assistant.
The most important information for the nurse to have when planning care for the client with diabetes is the client's
- A. Family medical history
- B. Blood glucose history
- C. 24-hour dietary history
- D. Medical history
Correct Answer: B
Rationale: Answer B is correct. The most objective answer is the blood glucose history. Answers A, C, and D are more subjective. This information is reported data.
The nurse helps the health care provider perform a thoracentesis at the bedside. In which position does the nurse place the client to facilitate needle insertion and promote comfort?
- A. Fetal position, lying on unaffected side with knees drawn to the abdomen and hands clasped around them
- B. Lying on the affected side with head of the bed elevated to 30-45 degrees
- C. Prone with head turned to the affected side and arms over the head, supported by a pillow
- D. Upright leaning forward over the bedside table, with arms supported on pillows
Correct Answer: D
Rationale: Upright leaning forward (D) facilitates lung expansion and fluid access while ensuring comfort. Other positions (A, B, C) are less effective or uncomfortable.