Nokea
The nurse is caring for clients on a medical-surgical floor. Which tasks related to pain management can be delegated to unlicensed assistive personnel (UAP)? Select all that apply.
- A. assessing the pain level on a scale of 1-10
- B. reminding clients to report pain immediately
- C. reporting facial grimacing in unresponsive clients
- D. asking clients directly, 'Are you having any pain right now?'
- E. giving acetaminophen (Tylenol) after the nurse obtains the medication but is interrupted to attend a code blue before she administers it
Correct Answer: B,C,D
Rationale: UAPs can remind clients to report pain (B), report objective signs like grimacing (C), and ask about pain presence (D), as these tasks do not require clinical judgment. Assessing pain levels (A) requires nursing judgment, and administering medications (E) is outside the UAP's scope.
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Which statement concerning informed consent is false?
- A. Persons 17 years of age and younger may not give informed consent.
- B. A married minor may not give informed consent.
- C. A pregnant minor may give informed consent.
- D. An adult 18 years of age and older may give informed consent.
Correct Answer: B
Rationale: Married minors can give informed consent, making this statement false. Pregnant minors and adults 18+ can also consent, while those 17 and younger typically cannot.
The nurse is preparing to interpret an electrocardiogram rhythm strip. Identify the order for interpreting the strip. Use all the options.
- A. measure the P-R interval
- B. determine the heart rate and rhythm
- C. analyze the P waves
- D. measure the QRS duration
Correct Answer: B,C,A,D
Rationale: The correct order is: determine heart rate and rhythm, analyze P waves, measure P-R interval, then QRS duration for systematic ECG interpretation.
The nurse is charting on his client, who had an open appendectomy the previous day. Which are appropriate nursing documentation entries? Select all that apply.
- A. The client appeared anxious when several family members came to visit.
- B. The client appeared angry when the health care provider changed her medications.
- C. The client tolerated 80% of the lunch tray with no complaints of nausea or stomach cramping.
- D. The client ambulated 200 feet in the hall with a cane. No dyspnea or syncope noticed. Tolerated well.
Correct Answer: C,D
Rationale: Objective entries about meal tolerance and ambulation are appropriate. Subjective terms like 'appeared anxious' or 'appeared angry' lack measurable data.
A 4-month-old infant is admitted to the pediatric unit for a 10-day course of antibiotics. The parents are only able to visit on weekends. Which action indicates the nurse understands the emotional needs of the infant?
- A. The nurse care plan calls for soothing music to be played several times per day.
- B. The nurse self-assigns care for the infant each shift worked.
- C. The nurse assigns a male nurse to care for the infant as much as possible.
- D. The nurse places the infant in a room close to the nursing station.
Correct Answer: A
Rationale: Soothing music addresses the infant's emotional needs by providing comfort in the absence of parents.
The ED nurse is attending orientation for nurses new to working in the ED. As part of the training, the ED nurse would expect to report which conditions to the proper authorities? Select all that apply.
- A. West Nile virus
- B. herpes simplex
- C. gunshot wounds
- D. elder abuse or neglect
- E. bites from an unknown dog
Correct Answer: A,C,D,E
Rationale: West Nile virus, gunshot wounds, elder abuse, and unknown dog bites are reportable due to public health or legal mandates.