Nokea
The nurse is caring for a client who is confused and is in soft wrist restraints. Which tasks can the nurse safely assign to unlicensed assistive personnel? Select all that apply.
- A. Assist the client with using a bedpan
- B. Check circulation and sensation of the extremities
- C. Perform range-of-motion exercises
- D. Report changes in skin integrity
- E. Turn and reposition the client in bed
Correct Answer: A,C,D,E
Rationale: UAP can assist with bedpan use (A), perform range-of-motion exercises (C), report skin changes (D), and reposition the client (E). Checking circulation and sensation (B) requires nursing assessment skills.
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The unlicensed assistive personnel notifies the charge nurse that the client is reporting feeling short of breath. What should the charge nurse do first?
- A. Activate a rapid response team
- B. Ask the unlicensed assistive personnel to take vital signs and report back
- C. Direct the client's primary nurse to examine the client
- D. Personally go and auscultate the client's lungs
Correct Answer: C
Rationale: Directing the primary nurse to assess the client ensures a timely, qualified evaluation of shortness of breath, a potentially serious symptom.
The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding?
- A. bounding pulse
- B. rapid respirations
- C. oliguria
- D. neck veins are distended
Correct Answer: C
Rationale: oliguria. Kidneys maintain fluid volume through adjustments in urine volume.
The nurse reinforces teaching to a client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide to treat active tuberculosis. Which of the following instructions associated with the adverse effects of rifampin is most important for the nurse to include?
- A. Notify the health care provider if your urine is red
- B. Take acetaminophen every 6 hours for drug-associated joint pain while taking this medication
- C. Wear eyeglasses instead of soft contact lenses while taking this medication
- D. You can stop taking the medications as soon as one sputum culture comes back normal
Correct Answer: C
Rationale: Rifampin can stain soft contact lenses orange-red, so wearing eyeglasses prevents this issue, making it a key instruction for adherence.
Which of the following is responsible for laws mandating the reporting of certain infections and diseases?
- A. Centers for Disease Control and Prevention (CDC)
- B. individual state laws
- C. National Institute of Health Research (NIH)
- D. Health and Human Services (HHS)
Correct Answer: B
Rationale: Individual state laws mandate the reporting of infectious diseases. The list of reportable diseases varies from state to state and is overseen by state health departments.
The nurse is planning care for a client who has a hearing impairment. Which action will likely help the most with communication?
- A. Repeat everything twice.
- B. Speak loudly.
- C. Speak slowly and clearly.
- D. Use gestures.
Correct Answer: C
Rationale: Speaking slowly and clearly enhances comprehension for hearing-impaired clients. Repeating, shouting, or gestures may confuse or overwhelm.