Nokea
The nurse enters a client’s room just as the unlicensed assistive personnel (UAP) is completing a bath and placing thigh-high anti-embolism stockings on the client. Which situation would cause the nurse to intervene?
- A. UAP applies the anti-embolism stockings while maintaining the client in supine position
- B. UAP carefully smoothes out any wrinkles over the length of the stockings
- C. UAP checks that the toe opening of the stockings is located on the plantar side of the foot
- D. UAP rolls down and folds over the excess material at the top of the stockings
Correct Answer: D
Rationale: Rolling and folding the stockings creates pressure points, risking skin breakdown and poor circulation. Supine application and correct toe opening placement are appropriate.
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The nurse approaches a 4-year-old boy to administer a medication. The child has no identification armband. Which action is most appropriate?
- A. Check the room and bed number the child is in with the room and bed number on the medication order and administer the medication if they agree
- B. Ask the child what his name is before administering the medication
- C. Ask the child if his name is George (the name on the medication order) and administer the medication if the child says that is his name
- D. Ask the adults at the bedside what the child's name is and administer the medication if the adults verify the name of the child
Correct Answer: D
Rationale: Verifying the child's identity with adults at the bedside ensures safety, as children may not reliably confirm their own identity, and room/bed numbers are not sufficient for identification.
A laboring woman prefers to lie in the supine position during labor. The nurse teaches her that this is not a good position for which reason?
- A. It will cause more back pressure.
- B. Her baby will not come down well into the pelvis.
- C. Her blood pressure may drop and cause the baby's heart rate to drop.
- D. Contractions will be too close together, not giving her a rest.
Correct Answer: C
Rationale: Supine position can compress the vena cava, causing maternal hypotension and reduced fetal perfusion, leading to fetal heart rate drops.
The nurse is caring for a client who is attempting to leave the hospital against medical advice. The client is competent to make decisions. Which of the following actions would be essential for the nurse to take?
- A. Provide the client with a copy of the client’s medical record
- B. Tell the client that discharge forms must be signed before leaving
- C. Inform the client that the client cannot return for medical care after leaving
- D. Ensure the health care provider explains the risks of leaving the hospital to the client
Correct Answer: D
Rationale: Ensuring the provider explains risks ensures informed decision-making, protecting the client and minimizing liability. Medical records are not immediately provided, forms are procedural, and barring future care is incorrect.
The nurse monitors a child who has been treated for an acute asthma exacerbation. Which finding is the best indicator that treatment has been effective?
- A. Episodes of spasmodic coughing have decreased
- B. No wheezes are audible on chest auscultation
- C. Oxygen saturation has increased from 88% to 93%
- D. Peak expiratory flow rate has dropped from 212 L/min to 127 L/min
Correct Answer: B
Rationale: Absence of wheezes indicates open airways, the primary goal of asthma treatment. Reduced coughing and improved oxygen saturation are positive but less specific than clear lungs.
The nurse is caring for a client who had a seizure 10 minutes ago. The client is now confused and reports a headache. Which of the following phases of seizure activity should the nurse recognize the client is experiencing?
- A. Ictal phase
- B. Aural phase
- C. Postictal phase
- D. Prodromal phase
Correct Answer: C
Rationale: The postictal phase follows a seizure, characterized by confusion and headache as the brain recovers. Ictal is the seizure itself, aural involves pre-seizure sensations, and prodromal is vague premonitory symptoms.