Nokea
The nurse is admitting a client who is blind and deaf. The nurse should prioritize which action?
- A. Review the plan of care with the client
- B. Communicate with the nursing supervisor with any safety concerns
- C. C. Update the client on the social activities
- D. D. Provide a safe environment for the client
Correct Answer: D
Rationale: Providing a safe environment (D) is the priority for a blind and deaf client to prevent injury, using tactile communication and clear pathways. Reviewing care plans (A), addressing concerns (B), or social updates (C) are secondary to immediate safety.
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The nurse is planning client care assignments. Which task should be delegated to the unlicensed assistive personnel (UAP)?
- A. The initial ambulation of a client following a laparoscopic hernia repair.
- B. Feed a client who has dysphagia.
- C. Applying sequential compression devices to a client’s lower extremities.
- D. Calling in prescriptions to the local pharmacy for a client ready for discharge.
Correct Answer: C
Rationale: Applying sequential compression devices (C) is a non-clinical task within the UAP’s scope. Initial ambulation (A), feeding with dysphagia (B), and calling prescriptions (D) require clinical judgment or RN/LPN skills due to risk or complexity.
The nurse is preparing to insert an indwelling urinary catheter. Which action may be delegated to the unlicensed assistive personnel (UAP)?
- A. Set up the sterile field
- B. Palpate the bladder for distention
- C. Explain the procedure to the client
- D. Place the urinary catheter kit at the bedside
Correct Answer: D
Rationale: Placing the catheter kit at the bedside (D) is a non-clinical task suitable for a UAP. Setting up a sterile field (A), palpating the bladder (B), and explaining the procedure (C) require clinical judgment or training beyond UAP scope.
The nurse in the emergency department (ED) is assessing a client involved in a motor vehicle crash who sustained a penetrating abdominal trauma. The client’s vital signs are: T 97.5°F (36.4°C); P 108 bpm; RR 22; BP 98/64 mm Hg; pulse oximetry 94% on room air. Which of the following actions should the nurse take first?
- A. Prepare the client for surgery.
- B. Insert a nasogastric (NG) tube.
- C. Auscultate the client’s bowel sounds.
- D. Reassess vital signs.
Correct Answer: D
Rationale: Reassessing vital signs (D) is the first action to confirm stability or deterioration in a client with penetrating abdominal trauma and tachycardia/hypotension, guiding further interventions. Surgery prep (A), NG tube (B), and bowel sounds (C) follow reassessment.
You are caring for a 33-year-old male client at the end of life. This married client has two children; the son is 14-years-old and the daughter is 8-years-old. Both of these children are being prepared for their father's imminent death. Which consideration should be incorporated into your explanations of death with these children?
- A. Children before the age of 12 view death as terrifying so the nurse should not discuss death with these young children.
- B. Children before the age of 12 do not have any perspectives about death, its meaning, and its finality or lack thereof.
- C. The cognitive development of young children impacts their understanding of death.
- D. The cognitive development of young children before 12 has no impact on their understanding of death
Correct Answer: C
Rationale: Cognitive development (C) influences how children, like the 8-year-old, understand death. Younger children may view death as reversible or temporary, while adolescents, like the 14-year-old, grasp its finality. Tailoring explanations to their developmental stage is essential. Options A and B are incorrect as children do have perspectives, and avoiding discussion (A) is unhelpful. Option D contradicts developmental psychology.
A hospitalized client tells the nurse that she has a living will prepared and that her lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse to help her obtain a witness for the will. Which of the following is the most appropriate response?
- A. I will sign as a witness to your signature.'
- B. Because it is a legal document, you will need to find a witness on your own.'
- C. Whoever is present at the time will sign as a witness for you.'
- D. I will contact the nursing supervisor for assistance regarding your request.'
Correct Answer: D
Rationale: Contacting the nursing supervisor (D) ensures compliance with legal witnessing requirements, as nurses may be restricted due to conflict of interest. Signing as a witness (A), leaving it to the client (B), or allowing anyone present (C) risks legal issues.