Nokea
The nurse in the long-term care facility must delegate a nursing task to an unlicensed assistive personnel. Which nursing task would be most appropriate to delegate?
- A. Comb the nits out of the client’s hair.
- B. Massage the reddened area on the hip.
- C. Scrape the burrows to remove the scabies mite.
- D. Apply antifungal lotion to the groin area.
Correct Answer: A
Rationale: Combing nits is a non-invasive task within UAP scope. Massaging, scraping, and applying medication require nursing judgment.
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A severely burned client is to be admitted from the emergency department. What type of room should the nurse prepare for the client?
- A. A semi-private room with a noninfectious client
- B. A room with a postoperative client
- C. An isolation room
- D. A private room with a private bath
Correct Answer: C
Rationale: An isolation room is necessary to reduce the risk of infection, a major complication in burn clients due to compromised skin barriers.
Which nursing instruction is most appropriate to convey to the client?
- A. Use hypoallergenic or glycerin soap for bathing.
- B. Apply lotion to the affected skin every other day.
- C. Take showers rather than tub baths.
- D. Rub the skin dry after bathing.
Correct Answer: A
Rationale: Hypoallergenic soap minimizes irritation in dry skin.
The nurse is assessing the client newly diagnosed with psoriasis. Which findings should the nurse expect? Select all that apply.
- A. Pruritus at the affected areas
- B. Nailbeds that are pink and clear
- C. Stringy, oily hair that falls out in clumps
- D. Lesions appear as red plaques with silvery scales
- E. Affected areas at elbows, knees, scalp, palms, or soles
Correct Answer: A,D,E
Rationale: Itching is a common symptom of psoriasis. Psoriatic patches are red, scaly plaques with silvery scales and occur most often on elbows, knees, scalp, palms, and soles. Nail involvement may include thickening, discoloration, and pitting; pink and clear describes normal nailbeds. Hair is dry and brittle, not oily.
Which nursing instruction is most appropriate before the client leaves the emergency department?
- A. Advise the client to limit dietary intake of fluids.
- B. Tell the client to sleep in a recliner or with the head up.
- C. Show the client how to take the carotid pulse at hourly intervals.
- D. Warn the client to avoid blowing the nose for several hours.
Correct Answer: D
Rationale: Avoiding nose blowing prevents dislodging clots and restarting bleeding.
The nurse writes the problem 'impaired skin integrity' for a client with stage IV pressure ulcers. Which interventions should be included in the plan of care? Select all that apply.
- A. Turn the client every three (3) to four (4) hours.
- B. Ask the dietitian to consult.
- C. Have the client sign a consent for pictures of the wounds.
- D. Obtain an order for a low air-loss bed.
- E. Elevate the head of the bed at all times.
Correct Answer: B,C,D
Rationale: Dietitian consult, wound photos (with consent), and low air-loss bed address stage IV ulcers. Turning every 3–4 hours is too infrequent, and constant head elevation increases coccyx pressure.