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The nurse is caring for a client with a spinal cord injury experiencing shock. Which task can be delegated to unlicensed assistive personnel?
- A. Transport the client to the radiology department
- B. Perform passive range of motion
- C. Gather cardiac monitoring equipment
- D. Obtain vital signs
Correct Answer: C
Rationale: Gathering cardiac monitoring equipment (C) is a non-clinical task within the UAP’s scope. Transport (A), range of motion (B), and vital signs (D) require clinical judgment or stability assessment, inappropriate for UAPs in a shock scenario.
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The nurse preceptor is observing a newly hired nurse care for assigned clients. It would require follow-up by the nurse preceptor if the newly hired nurse is observed doing which of the following?
- A. Humidifies nasal cannula oxygen for a client with sarcoidosis.
- B. Secures a suprapubic catheter tubing to a client’s inner thigh.
- C. Places a client with varicella-zoster in airborne and contact isolation.
- D. Suctions a tracheostomy for 10 seconds as they remove the catheter.
Correct Answer: D
Rationale: Suctioning a tracheostomy for 10 seconds (D) risks hypoxia and trauma, requiring follow-up as it should be brief (5-10 seconds max). Humidifying oxygen (A), securing catheters (B), and isolating varicella (C) are correct practices.
The nurse is caring for a client who reports having a durable power of attorney. The nurse understands that this type of advance directive is
- A. a person who makes decisions for a client once the health care provider states the client no longer has the capacity to make their own health care decisions.
- B. a legal document that tells health care providers and family members about which life-sustaining treatment is wanted or unwanted if the client is unable to make decisions.
- C. a legal document in which a client designates someone else to make medical decisions for them when the client can no longer do so.
- D. a specific designation specifying who can receive and discuss the client's privileged healthcare information.
Correct Answer: C
Rationale: A durable power of attorney for healthcare (C) is a legal document designating a proxy to make medical decisions when the client is incapacitated. Option (A) describes the role, not the document. Option (B) describes a living will, and (D) refers to HIPAA authorization, not an advance directive.
A client has just been diagnosed with a terminal illness. She decides to execute a living will in the unit and asks the nurse to be the witness of the will. What is the most appropriate response by the nurse?
- A. I'm sorry, but under the law, we're not allowed to witness living wills.'
- B. Let me call the doctor. Maybe he can witness it for you.'
- C. Your family are the only people that can serve as witnesses.'
- D. Let me call the hospital attorney; he needs to be present when you sign your will.'
Correct Answer: A
Rationale: In many jurisdictions, nurses are restricted from witnessing living wills (A) due to potential conflicts of interest. Doctors (B) or attorneys (D) are not required, and family-only witnesses (C) is incorrect, as non-family can witness.
The nurse is caring for assigned clients with newly received prescriptions. Which prescription should the nurse administer first? See the exhibit.
- A. Levofloxacin 750 mg IVPB Q12 hours
- B. 0.9% Saline 125 ml/hr
- C. Metoclopramide 10 mg IV Push Q8 hours
- D. Ketorolac 15 mg IV Push Q8 hours
Correct Answer: A
Rationale: Pneumonia in an elderly client can be particularly severe due to age-related immune system decline and potential for complications like acute respiratory distress syndrome (ARDS) and/or sepsis.
The nurse has received the following prescriptions for newly admitted clients. Which medication should the nurse administer first?
- A. Subcutaneous (SubQ) epoetin for anemia
- B. oxycodone by mouth (PO) for pain control
- C. Intravenous (IV) fluids for sepsis
- D. Intramuscular (IM) hydroxyzine for anxiety
Correct Answer: C
Rationale: IV fluids for sepsis (C) are the priority to restore perfusion and prevent organ failure. Epoetin (A) addresses chronic anemia, oxycodone (B) manages pain, and hydroxyzine (D) treats anxiety, all less urgent than sepsis.