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The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Test blood sugar every 2 hours by Accu-Check
- B. Review with family and client signs of hyperglycemia
- C. Monitor for mental status changes
- D. Check skin condition of lower extremities
Correct Answer: A
Rationale: The UAP can do standard, unchanging procedures. Testing blood sugar with an Accu-Check is a routine task that does not require clinical judgment, making it appropriate for delegation to a UAP.
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The orientation nurse educator reviewing the biohazard legend with a class of new employees states that the emblem is affixed to containers whenever:
- A. there is presence of blood and body fluids.
- B. there is the need for droplet precaution.
- C. there is contact isolation.
- D. there is the potential for airborne transmission.
Correct Answer: A
Rationale: When body substances are handled, the potential for transmission is increased; therefore, federal regulations require warning labels to communicate with other employees and/or waste collectors. The biohazard alert is a three-ring symbol overlaying a central concentric ring. Blood, drainage from wounds, feces, and urine are all body fluids that can transfer infection and disease to others.
The nurse is to administer a new medication to a client. Which of these actions best demonstrate awareness of safe, proficient nursing practice?
- A. Verify the order for the medication. Prior to giving the medication the nurse should say, 'Please state your name.'
- B. Upon entering the room the nurse should ask: 'What is your name? What allergies do you have?' and then check the client's name band and allergy band.
- C. As the room is entered say 'What is your name?' then check the client's name band.
- D. Verify the client's allergies on the chart and confirm the client's name on the name band.
Correct Answer: B
Rationale: Asking the client to state their name and allergies, then verifying with the name band and allergy band, ensures accurate identification and safety.
After securing the client's safety from a faulty electric bed, the nurse should take which action?
- A. Discuss the matter with the client's significant others.
- B. Document the incident in the client's record in detail.
- C. Notify the physician.
- D. Prepare an incident report.
Correct Answer: D
Rationale: After the situation is safe for the client, the nurse should record the occurrence on an incident form according to the agency protocol.
The client with a right femoral arterial line is confused, thrashing about in bed, and picking at the tubing. The HCP prescribes wrist restraints. Based on this information, what should the nurse plan to do?
- A. Apply the wrist restraints as prescribed
- B. Request an order for a right ankle restraint also
- C. Request an order for sedation instead of restraints
- D. Question the order; restraints will increase the client's agitation
Correct Answer: B
Rationale: An ankle restraint is needed to prevent leg movement that could dislodge the femoral arterial line, which wrist restraints alone cannot address.
A newborn has been delivered. An Apgar score is given. What does this scoring system indicate?
- A. heart rate, respiratory effort, color, muscle tone, reflex irritability
- B. heart rate, bleeding, cyanosis, edema
- C. bleeding, reflex, edema
- D. respiratory effort, heart rate, seizures
Correct Answer: A
Rationale: The Apgar scoring system was put into place by Virginia Apgar, an anesthesiologist in New York, for the purpose of assessing newborns in the areas of heart rate, respiratory effort, color, muscle tone, and reflex irritability at 1, 5, and sometimes 10 minutes after birth.