Nokea
The nurse is caring for a newly admitted client. Which task can the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Apply nasal cannula oxygen
- B. Remove a vascular access device that is not patent
- C. Perform venipuncture for laboratory work
- D. Obtain vital signs every four hours
Correct Answer: D
Rationale: Obtaining vital signs every four hours (D) is a routine task within the UAP’s scope. Applying oxygen (A), removing vascular access (B), and venipuncture (C) require nursing skills and judgment.
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The nurse is planning a staff development conference about the care of transgender clients. Which of the following information should the nurse include? Select all that apply.
- A. At the start of the interview, inquire about the client's preferred pronoun.'
- B. Utilize binary gender terms on healthcare documentation.'
- C. Transgender individuals feel a variance between gender and natal sex.'
- D. Clients who are transgender may be reluctant to seek healthcare.'
- E. Inquire about any current or future plans for hormone therapy.'
Correct Answer: A, C, D, E
Rationale: Inquiring about pronouns (A), recognizing gender variance (C), acknowledging healthcare reluctance (D), and discussing hormone therapy (E) are inclusive and relevant. Binary gender terms (B) are inappropriate, as they exclude non-binary identities.
The nurse approached a client with a blood pressure cuff, and the client extended their arm to allow the nurse to obtain a reading. The nurse understands that this exemplifies what type of consent?
- A. Informed consent
- B. Implied consent
- C. Expressive consent
- D. Written consent
Correct Answer: B
Rationale: Extending an arm for a blood pressure reading (B) is implied consent, as the client’s action indicates agreement. Informed consent (A) requires explanation, expressive consent (C) is not a standard term, and written consent (D) is for procedures.
The medical-surgical nurse is preparing for the admission of an older adult following a ground-level fall. The nurse should prioritize teaching the client
- A. how to use the telephone and order meals.
- B. their prescribed medications for the shift.
- C. the prescribed pain management plan.
- D. how to operate the call light.
Correct Answer: D
Rationale: Teaching how to operate the call light (D) is the priority to ensure the client can request assistance, preventing falls and ensuring safety. Telephone use (A), medications (B), and pain management (C) are important but secondary to immediate safety needs.
The nurse has been made aware that the following clients require assistance. The nurse should first assist the client
- A. experiencing a flare-up of ulcerative colitis and has had 2 bloody bowel movements in the past hour.
- B. with a cerebral aneurysm, has developed nausea and vomiting.
- C. taking prescribed prednisone for an allergic reaction and reports indigestion.
- D. being treated for Bell's palsy and reports ringing in their ears.
Correct Answer: A
Rationale: Bloody bowel movements in ulcerative colitis (A) suggest active bleeding, requiring immediate assistance to prevent hypovolemia. Nausea with aneurysm (B), indigestion with prednisone (C), and tinnitus with Bell’s palsy (D) are less urgent.
The registered nurse (RN) supervises a licensed practical/vocational nurse (LPN). Which statement by the LPN/VN requires follow-up by the RN?
- A. I bathed the client already this morning'
- B. I passed out letters and packages to the clients this morning.'
- C. The client refused his prescribed valproic acid, so I snuck it into his food.'
- D. I will be joining the clients with their games today in the day room.'
Correct Answer: C
Rationale: Hiding medication in food (C) is unethical, unsafe, and violates client autonomy, requiring immediate RN follow-up. Bathing (A), distributing mail (B), and joining games (D) are within the LPN’s scope and do not require intervention.