Nokea
The nurse is caring for clients on a surgical unit. Which nursing task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?
- A. Help the client with a two (2)-day postop amputation put on the prosthesis.
- B. Request the UAP double-check a unit of blood to be hung.
- C. Change the surgical dressing on the client with a Syme's amputation.
- D. Ask the UAP to take the client to the physical therapy department.
Correct Answer: D
Rationale: Transporting a client to PT is within UAP scope. Prosthesis application, blood verification, and dressing changes require nursing judgment.
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The nurse supervises a nursing assistant who is applying the client's antiembolism stockings. What is the correct technique for applying these stockings?
- A. The nursing assistant applies the stockings before getting the client out of bed.
- B. The nursing assistant applies the stockings just before helping the client do leg exercises.
- C. The nursing assistant applies the stockings after nursing that the client's legs are cool.
- D. The nursing assistant applies the stockings at night before the client's bedtime.
Correct Answer: A
Rationale: Applying antiembolism stockings before the client gets out of bed ensures compression is in place during upright positions when venous pooling is most likely. Applying them later or based on leg temperature is less effective.
Which is the best material for the nurse to place under a wet cast immediately after application?
- A. Synthetic sheepskin
- B. A vinyl sheet
- C. An absorbent pad
- D. Several pillows
Correct Answer: D
Rationale: Several pillows elevate the casted extremity, promoting venous return and reducing swelling while the cast dries, without absorbing moisture or causing pressure points. Sheepskin and vinyl are less effective, and absorbent pads may retain moisture.
The nurse correctly instructs the client to avoid which type of fluid?
- A. Milk
- B. Alcohol
- C. Cranberry juice
- D. Carbonated drinks
Correct Answer: B
Rationale: Alcohol increases uric acid levels, worsening gout.
To prevent skin breakdown while the client is in Russell's traction, the nurse must frequently inspect the skin in which area?
- A. Over the ischial spines
- B. In the popliteal space
- C. Near the iliac crests
- D. At the zygomatic arch
Correct Answer: B
Rationale: Russell's traction involves a sling under the knee, placing pressure on the popliteal space, which is prone to skin breakdown due to prolonged contact and immobility. Frequent inspection here prevents pressure ulcers.
Which foods should the nurse recommend to a client when discussing sources of dietary calcium?
- A. Yogurt and dark-green, leafy vegetables.
- B. Oranges and citrus fruits.
- C. Bananas and dried apricots.
- D. Wheat bread and bran.
Correct Answer: A
Rationale: Yogurt and dark-green leafy vegetables (e.g., kale) are rich in calcium, supporting bone health. Other options have minimal calcium content.