Nokea
The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required?
- A. I need to have the entire house treated by pest control to ensure the bed bugs are gone.
- B. I should concentrate on alleviating scratching as it can cause further complications.
- C. My other family members and pets are at risk of bed bug bites.
- D. This must have happened because I did not wash the bed sheets this week.
Correct Answer: D
Rationale: Bed bug infestations are not caused by unwashed sheets but by exposure to infested environments. This misconception indicates a need for further teaching about bed bug transmission and prevention.
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A client hospitalized with mania is racing wildly about the unit trying to organize the other clients into a game of Ping-Pong. The nurse should:
- A. Send the client to the recreation room for art therapy.
- B. Take the client outside for a walk.
- C. Allow the client to continue because his activities are goal directed.
- D. Suggest that the client do exercises to a video instead.
Correct Answer: B
Rationale: Taking the client for a walk redirects energy safely and reduces stimulation. Art therapy may not engage, continuing the activity risks escalation, and video exercises lack supervision.
While the nurse is preparing medications, a code occurs. One of the nursing assistants offers to help by administering the medications. What is the best response by the nurse?
- A. Allow the nursing assistant to give the medications
- B. Hold the medications until after the code
- C. Give the medications and then help with the code
- D. Ask the nursing assistant when she was checked off on giving medications
Correct Answer: B
Rationale: Holding medications prioritizes the code response, as CNAs cannot administer medications, ensuring patient safety and appropriate task delegation.
Which one of these tasks can be safely delegated to a practical nurse (PN)?
- A. Assess the function of a newly created ileostomy
- B. Care for a client with a recent complicated double barrel colostomy
- C. Provide stoma care for a client with a well functioning ostomy
- D. Teach ostomy care to a client and their family members
Correct Answer: C
Rationale: Provide stoma care for a client with a well functioning ostomy. The care of a mature stoma and the application of an ostomy appliance may be delegated to a PN. This client has minimal risk of instability of the situation.
The nurse is assigning client care tasks to unlicensed assistive personnel. Which statement by the nurse is appropriate?
- A. I need you to take vital signs on all clients in rooms 1 through 10 this morning
- B. Mrs. Jones fell out of bed during the night while walking to the commode. Please monitor her closely.
- C. Please ensure that Mr. Garcia in room 8 ambulates several times.
- D. Please take Mr. Wu's vital signs in 10 minutes and let me know if his systolic blood pressure is <100.
Correct Answer: A
Rationale: Assigning vital signs for multiple clients is clear, specific, and within the UAP's scope of practice, ensuring safe delegation.
The nurse is caring for a client with a vascular access for hemodialysis. Which of these findings necessitates immediate action by the nurse?
- A. pruritic rash
- B. dry, hacking cough
- C. chronic fatigue
- D. elevated temperature
Correct Answer: D
Rationale: It is a priority to report this finding since clients on hemodialysis are prone to infection, and the first sign is an elevated temperature.