Nokea
The nurse is delegating tasks to an experienced, unlicensed assistive personnel (UAP). Which of the following clients should the nurse delegate to the UAP?
- A. a client with multiple pressure ulcers requiring daily dressing changes
- B. a client with a permanent tracheostomy requiring daily tracheostomy care
- C. a client recovering from pneumonia with orders to ambulate in the hall BID
- D. a client who just received pain medication and needs to have her pain level assessed in 30 minutes
Correct Answer: C
Rationale: Ambulating a client is within a UAP’s scope, requiring minimal clinical judgment, unlike wound care, tracheostomy care, or pain assessment.
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A 14-year-old client has been diagnosed with celiac disease after a long history of diarrhea, anemia, and weight loss. What type of diet does the nurse anticipate the client will require?
- A. High protein
- B. Dairy free
- C. Low carbohydrate
- D. Gluten free
Correct Answer: D
Rationale: Celiac disease requires a gluten-free diet (D) to prevent intestinal damage. Other diets (A, B, C) are not specific to celiac.
The nurse is assessing a client for hypovolemia. Which laboratory result would help the nurse in confirming a volume deficit?
- A. Hematocrit 55%
- B. Potassium 5.0 mEq/L
- C. Urine specific gravity 1.016
- D. BUN 18 mg/dL
Correct Answer: A
Rationale: Hypovolemia causes hemoconcentration, increasing hematocrit (e.g., 55% is elevated). Potassium, urine specific gravity, and BUN within normal ranges don't confirm volume deficit.
A client is admitted to the emergency room with a gunshot wound to the right arm. After dressing the wound and administering the prescribed antibiotic, the nurse should:
- A. Ask the client if he has any medication allergies
- B. Check the client's immunization record
- C. Apply a splint to immobilize the arm
- D. Administer medication for pain
Correct Answer: C
Rationale: Immobilizing the arm with a splint prevents further tissue damage and promotes healing, which is a priority after initial wound care and antibiotic administration. Checking for allergies should have been done prior to administering antibiotics, and pain management, while important, is secondary to stabilization.
The nurse is assigned a male client with a long-term in-dwelling catheter for incontinence. The nurse plans on performing which of the following to prevent complications?
- A. perform perineal care using sterile technique
- B. irrigate daily with 60 cc normal saline
- C. restrict fluids to 1,500 cc/day
- D. stabilize the catheter on the abdomen
Correct Answer: D
Rationale: Stabilizing the catheter prevents traction and urethral trauma. Perineal care uses clean technique, routine irrigation is unnecessary, and fluid restriction is inappropriate.
The nurse is assessing a client with a closed reduction of a fractured femur. Which finding should the nurse report to the physician?
- A. Chest pain and shortness of breath.
- B. Ecchymosis on the side of the injured leg.
- C. Oral temperature of 99.2°F.
- D. Complaints of level two pain on a scale of five.
Correct Answer: A
Rationale: Chest pain and shortness of breath may indicate a pulmonary embolism, a serious complication requiring immediate reporting.