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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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A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. The nurse should reinforce teaching about which intervention related to the drug's adverse effects?
- A. Have an ophthalmologic examination every 6 months
- B. Take the medication on an empty stomach
- C. Take vitamin D and calcium supplements
- D. Wear a MedicAlert bracelet
Correct Answer: A
Rationale: Hydroxychloroquine can cause retinal toxicity. Regular ophthalmologic exams every 6 months are essential to monitor for early signs of retinal damage.
The nurse has an order to administer ophthalmic drops and ophthalmic ointment to a client being treated for conjunctivitis. The nurse should:
- A. Apply the eye ointment and eye drops together.
- B. Apply the eye drops, wait 5 minutes, and apply the ointment.
- C. Apply the eye ointment, wait 30 minutes, and apply the eye drops.
- D. Ask the pharmacist to supply the two medications in the same form.
Correct Answer: B
Rationale: Applying drops first, then waiting 5 minutes before ointment, ensures proper absorption of both. Ointment first would block drops, and combining forms is unnecessary.
The mother of a boy who has recently been diagnosed with sickle cell anemia is pregnant and asks the nurse if her unborn baby will have sickle cell anemia. What information should the nurse include in the answer?
- A. Sickle cell anemia is a contagious disease, but your child should no longer be communicable by the time the baby is born.
- B. When both parents are carriers, there is a 25% chance that each child will have sickle cell anemia.
- C. Your sons have a 50% chance of having sickle cell anemia, but daughters can only be carriers.
- D. The next child should be disease free, but additional children have a chance of being born with the disease.
Correct Answer: B
Rationale: Sickle cell anemia is autosomal recessive; if both parents are carriers, each child has a 25% chance of inheriting the disease, regardless of sex or birth order.
Which one of these tasks can be safely delegated to a practical nurse (PN)?
- A. Assess the function of a newly created ileostomy
- B. Care for a client with a recent complicated double barrel colostomy
- C. Provide stoma care for a client with a well functioning ostomy
- D. Teach ostomy care to a client and their family members
Correct Answer: C
Rationale: Provide stoma care for a client with a well functioning ostomy. The care of a mature stoma and the application of an ostomy appliance may be delegated to a PN. This client has minimal risk of instability of the situation.
A 20-year-old woman is admitted to the hospital following an accident. Her uncle, a physician from out of state, visits her and asks to see her chart. How should the nurse respond?
- A. Comply with the request and give the chart to the physician
- B. Explain that written permission from his niece is needed first
- C. Suggest that he discuss the case with the attending physician
- D. Give him the chart but do not let him remove it from the nurse's station
Correct Answer: B
Rationale: HIPAA regulations require patient consent for chart access, even by a physician relative, unless they are directly involved in care. Permission from the patient is needed first.