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The nurse is making assignments for the day. The staff consists of an RN, an LPN, and a nursing assistant. Which client should be assigned to the nursing assistant?
- A. A client with laparoscopic cholecystectomy
- B. A client with viral pneumonia
- C. A client with suspected ectopic pregnancy
- D. A client with intermittent chest pain
Correct Answer: B
Rationale: A nursing assistant can provide basic care such as hygiene and vital signs for stable clients. A client with viral pneumonia, if stable, requires less complex care compared to post-surgical , potential emergency , or cardiac clients, which require licensed staff.
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The best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus is:
- A. Impaired Skin Integrity.
- B. Knowledge Deficit: New Diabetes Diagnosis.
- C. Alteration in Nutrition: More than Body Requirements.
- D. Fluid Volume Deficit.
Correct Answer: B
Rationale: Newly diagnosed diabetics need to learn about their disease, medications, glucose testing, possibly insulin injections, foot care, sick-day plans, and so forth.
Which of the following instructions should be included in the teaching for the client with arthritis?
- A. Avoid exercise because it fatigues the joints.
- B. Take prescribed anti-inflammatory medications with meals.
- C. Alternate heat and cold packs to the affected joints.
- D. Avoid weight bearing activity.
Correct Answer: B
Rationale: Taking anti-inflammatory medications with meals reduces gastrointestinal irritation, a key teaching point for arthritis management. Exercise and weight-bearing activities are encouraged, and heat/cold alternation is not universally recommended.
A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack?
- A. Cheese crackers
- B. Peanut butter sandwich
- C. Potato chips
- D. Vanilla cookies
Correct Answer: C
Rationale: Children with celiac disease should eat a gluten free diet. Potato chips are naturally gluten-free, unlike the other options which contain wheat-based ingredients.
The nurse is developing a care plan for a client with severe anxiety. An appropriate outcome for the client is that within 4 days the client should:
- A. Have decreased anxiety.
- B. Talk to the nurse for 10 minutes.
- C. Sit quietly for 30 minutes.
- D. Develop an adaptive coping mechanism.
Correct Answer: B
Rationale: Outcome criteria need to be specific, measurable, and realistic. Talking for 10 minutes meets all of these conditions.
The nurse is caring for a client who is receiving a continuous IV infusion of propofol (Diprivan) for sedation. Which of the following findings should the nurse report immediately?
- A. Respiratory rate of 12 breaths/min.
- B. Blood pressure of 100/60 mmHg.
- C. Heart rate of 80 bpm.
- D. Oxygen saturation of 90%.
Correct Answer: D
Rationale: An oxygen saturation of 90% indicates hypoxemia, a serious propofol side effect. Options A, B, and C are acceptable.