Nokea
The nurse is making assignments for the day's care. Which assignment should not be given to the nursing assistant?
- A. Emptying the Foley catheter bag
- B. Administering a Fleet's enema
- C. Measuring the oral intake
- D. Feeding a client with depression
Correct Answer: B
Rationale: Administering an enema requires nursing judgment and is outside a nursing assistant's scope. Other tasks are appropriate for a nursing assistant.
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The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used to
- A. determine oxygen saturation
- B. measure forced expiratory volume
- C. monitor atmosphere for severe of allergens
- D. provide metered doses for inhaled bronchodilator
Correct Answer: B
Rationale: The peak flow meter is used to measure peak expiratory flow volume. It provides useful information about the presence and/or severity of airway obstruction.
A woman is admitted with Hodgkin's disease. Which does the nurse expect the client to report?
- A. Swollen lymph nodes
- B. A painful rash
- C. Stomach pain
- D. Joint pain
Correct Answer: A
Rationale: Hodgkin's disease typically presents with painless swollen lymph nodes, a hallmark symptom the nurse should expect.
Vital signs
Temperature 95 F (35 C)
Blood pressure 90/50 mm Hg
Heart rate 50/min
Respirations 6/min
SpO2 83%
The nurse is caring for a client with hypothyroidism who has become lethargic and difficult to rouse. Which action is the priority?
- A. Administer scheduled PO levothyroxine
- B. Perform bag-valve-mask ventilation
- C. Place a warming blanket on the client
- D. Review client's thyroid laboratory results
Correct Answer: B
Rationale: Lethargy and unresponsiveness in hypothyroidism suggest myxedema coma, requiring immediate airway management with ventilation (B). Levothyroxine (A), warming (C), and lab review (D) are secondary.
In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?
- A. White patches
- B. Green drainage
- C. Reddened tissue
- D. Eschar development
Correct Answer: C
Rationale: Reddened tissue. Redness indicates granulation tissue formation, a sign of healing.
The nurse is caring for a hospitalized client. Which is the best example of narrative documentation to provide legal malpractice protection for the nurse after an adverse event?
- A. Client found on floor this morning at 6:50 AM. No verbalized symptoms. I think client tripped over a cord. Client instructed on safety during ambulation.'
- B. Client reports IV pole hit head at 7:30 AM. Denies pain. IV pole removed for client safety. Will continue to monitor. Health care provider (HCP) notified.'
- C. IV site in right hand is red and swollen at 9:30 AM. IV line removed, bleeding controlled, and warm compress administered at 9:40 AM. Will monitor for swelling and pain every hour.'
- D. Package of green leaves found in client drawer at 1:00 PM. Client acting suspicious at 2:00 PM. HCP notified. Will call security. Client has multiple tattoos and piercings.'
Correct Answer: C
Rationale: Detailed, objective documentation (C) with times, actions, and follow-up plans provides the best legal protection. Options A, B, and D include assumptions, vague details, or irrelevant information.