Nokea
The nurse has several tasks that need to be completed. Which of the following client assignments would be appropriate to delegate to the unlicensed assistive personnel?
- A. A 65-year-old male requiring sterile dressing changes.
- B. A 26-year-old female requiring a one-person assist in ambulating to the restroom.
- C. An 80-year-old male who is receiving enteral feedings continuously through an NG tube.
- D. A 23-year-old client requiring frequent urinary specimen collections from their indwelling urinary catheter.
Correct Answer: B
Rationale: Assisting a client with ambulation (B) is a non-clinical task within the UAP’s scope. Sterile dressing changes (A), enteral feedings (C), and catheter specimen collection (D) require clinical judgment or training beyond UAP scope.
You may also like to solve these questions
The nurse is caring for four clients on a medical-surgical unit. Which of the following tasks would be a priority for the nurse to complete?
- A. teaching a client scheduled for discharge how to ambulate with crutches
- B. witnessing informed consent for a client needing an emergency laparotomy
- C. irrigating a client's ostomy who reports abdominal cramping
- D. calculating the intake and output of a client with diabetes insipidus (DI)
Correct Answer: B
Rationale: Witnessing informed consent for an emergency laparotomy (B) is a priority, as it ensures legal and ethical requirements are met for urgent surgery. Crutch training (A), ostomy irrigation (C), and intake/output calculation (D) are important but less time-sensitive.
The nurse reviews the client's emergency department (ED) triage note. Which action should the nurse take first? See the image below.
- A. Establish continuous cardiac monitoring
- B. Obtain an order for a complete metabolic panel
- C. Obtain a prescription for acetaminophen (APAP)
- D. Apply a cool compress to the client's forehead
Correct Answer: A
Rationale: This client is showing manifestations of digitalis toxicity. The client's bradycardia, anorexia, and vomiting are classic signs of this potentially fatal toxicity. The nurse should immediately establish continuous cardiac monitoring because, if untreated, digitalis toxicity may cause multifocal premature ventricular contractions (PVCs) that may transition to ventricular tachycardia or ventricular fibrillation. Because of digitalis' ability to have a negative chronotropic effect, bradycardia is often seen in toxicity.
The nurse working on a medical-surgical unit is caring for assigned clients. The nurse should plan to initially assess the client who
- A. had a subtotal thyroidectomy 12 hours ago and reports difficulty swallowing.
- B. reports increased pain following a sterile dressing change for a stage IV pressure ulcer.
- C. has bilateral lower lobe pneumonia and has not used the incentive spirometer in six hours.
- D. is scheduled for an adrenalectomy in eight hours and has not signed the informed consent.
Correct Answer: A
Rationale: Difficulty swallowing post-thyroidectomy (A suggests complications like hematoma or nerve injury, which can be life-threatening and require immediate assessment. Increased pain (B), and not using an incentive spirometer (C), and lack of consent (D) are less urgent and critical.
The nurse has administered prescribed medications to assigned clients. Which follow-up assessment requires immediate follow-up? A client who received prescribed
- A. intravenous hydromorphone for chronic back pain and is drowsy.
- B. intravenous metoclopramide for nausea and vomiting and now has involuntary movements of the jaw.
- C. intravenous dexamethasone for chronic bronchitis reporting perineal itching.
- D. nitroglycerin infusion for chest pain and reports a headache.
Correct Answer: B
Rationale: Involuntary jaw movements after intravenous metoclopramide (B) indicate extrapyramidal symptoms, a serious adverse reaction that may progress to dystonia, requiring immediate intervention like stopping the drug or administering an antidote (e.g., diphenhydramine). Drowsiness with hydromorphone (A), perineal itching with dexamethasone (C), and headache with nitroglycerin (D) are expected side effects and less urgent.
The nurse has learned during nursing school to maintain honesty and openness with all clients, even when conveying potentially distressing information. This approach aligns with the ethical principle of
- A. beneficence.
- B. veracity.
- C. nonmaleficence.
- D. fidelity.
Correct Answer: B
Rationale: Honesty and openness (B) align with veracity, the ethical principle of truth-telling. Beneficence (A) promotes well-being, nonmaleficence (C) avoids harm, and fidelity (D) keeps promises, but veracity is most relevant here.