Nokea
The nurse is caring for a client with tuberculosis who is on airborne isolation precautions. The nurse can delegate which tasks to experienced unlicensed assistive personnel? Select all that apply.
- A. Alert the x-ray department about maintaining airborne isolation precautions
- B. Explain to the client why the client must wear a mask during transport to another department
- C. Post signs for airborne isolation precautions on the client's door and stock necessary equipment
- D. Remind visitors to wear a respirator mask and keep the door closed while in the client's room
- E. Talk with the family about the reasons for airborne isolation precautions in the client
Correct Answer: C, D
Rationale: Posting signs and stocking equipment (C) and reminding visitors about precautions (D) are within UAP scope. Alerting departments (A), explaining to the client (B), and educating family (E) require nursing judgment.
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The spouse of a client with Alzheimer's disease expresses concern about the burden of caregiving. Which of the following actions by the nurse should be a priority?
- A. Link the caregiver with a support group
- B. Ask friends to visit regularly
- C. Schedule a home visit each week
- D. Request anti-anxiety prescriptions
Correct Answer: A
Rationale: Assisting caregivers to locate and join support groups is most helpful. Families share feelings and learn about services such as respite care. Health education is also available through local and national Alzheimer's chapters.
The nurse has reinforced teaching with a client with newly diagnosed polycythemia vera. Which of the following statements by the client would require follow-up?
- A. I should take an iron supplement daily.'
- B. I should increase my daily fluid intake.'
- C. I may require frequent phlebotomy.'
- D. I will take a low-dose aspirin daily.'
Correct Answer: A
Rationale: Iron supplements (A) can worsen polycythemia vera by increasing red blood cell production, requiring follow-up. Increased fluids (B), phlebotomy (C), and aspirin (D) are appropriate.
The nurse is reviewing discharge teaching for a client who had surgical repair of a retinal detachment. Which of the following instructions are appropriate for the nurse to include in the teaching? Select all that apply.
- A. Avoid rubbing or scratching the affected eye
- B. Avoid straining when having a bowel movement
- C. Expect occasional flashes of light during recovery
- D. Report any sudden pain to the health care provider
- E. Rest the eyes by refraining from reading and writing
Correct Answer: A, B, D
Rationale: Avoiding rubbing (A), straining (B), and reporting sudden pain (D) prevent complications. Flashes (C) are not expected and require reporting, and eye rest (E) is unnecessary unless specified.
The nurse caring for a 2-year-old client should expect the child to be able to perform which of the following actions? Select all that apply.
- A. Draw a square
- B. Hop on one foot
- C. Kick a large ball
- D. Use 2-word phrases
- E. Walk without help
Correct Answer: C, D, E
Rationale: A 2-year-old can kick a ball (C), use 2-word phrases (D), and walk without help (E). Drawing a square (A) and hopping on one foot (B) are skills typically developed later.
A client receiving aminophylline IV complains of feeling nervous and shaky. The nurse is aware that these are symptoms of:
- A. CNS depression that accompanies xanthine derivatives
- B. CNS stimulation that sometimes accompanies xanthine derivatives
- C. The anticholinergic effects of aminophylline
- D. Cardiovascular depression that can accompany xanthine derivatives
Correct Answer: B
Rationale: Aminophylline, a xanthine derivative, can cause CNS stimulation, leading to nervousness and shakiness. It does not typically cause CNS or cardiovascular depression or anticholinergic effects.