Nokea
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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A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?
- A. Explain to the client that the dentures must come out as they may get lost or broken in operating room
- B. Ask the client if there are second thoughts about having the procedure
- C. Notify the anesthesia department and the surgeon of the client's refusal
- D. Ask the client if the preference would be to remove the dentures in the operating room receiving area
Correct Answer: D
Rationale: Ask the client if the preference would be to remove the dentures in the operating room receiving area. Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client's sense of self-esteem and self-concept.
The nurse is caring for the client who received afterload internal radiotherapy (brachytherapy) for treatment of uterine cancer. The nurse manager evaluates that the nurse uses correct hazardous material precautions when noting that the nurse takes which action?
- A. Double-bags linens before removing them from the client's room
- B. Minimizes the amount of time spent in contact with the client
- C. Maintains a distance of 1 foot away from the client
- D. Wears lead gloves and apron and a dosimetry badge with client contact
Correct Answer: B
Rationale: Minimizing time spent with the client reduces radiation exposure, a key precaution in brachytherapy.
The nurse is planning care for an 18 month-old child. Which action should be included in the child's care?
- A. Hold and cuddle the child frequently
- B. Encourage the child to feed himself finger food
- C. Allow the child to walk independently on the nursing unit
- D. Engage the child in games with other children
Correct Answer: B
Rationale: Encourage the child to feed himself finger food. According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living that allow the toddler to assert his budding sense of control.
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.
The nurse manager overhears multiple conversations on a hospital unit. Based on the statement made, the nurse manager should initiate the process for reporting incivility with which person?
- A. Charge nurse to the nurse, "I need to discuss the medication error you made yesterday."
- B. HCP to the nurse, "Tell me again what the client's vital signs were before I collapsed."
- C. Nurse to a coworker, "You forgot to document the client's noon glucometer reading."
- D. HCP to the client, "I can't do anything more for you; you don't follow my advice anyway."
Correct Answer: D
Rationale: The HCP's statement to the client is demeaning and uncivil, warranting a report for incivility.