Nokea
The nurse is observing a staff member caring for a client who has varicella with active lesions. The nurse should intervene if the staff member is observed
- A. removing the protective gown with the contaminated side facing away from the body
- B. placing a surgical mask on the client before transport outside of the client's room
- C. removing the N95 respirator mask while inside the client's room
- D. keeping the door to the client's room closed at all times
Correct Answer: C
Rationale: Removing an N95 mask inside the room of a varicella client risks airborne exposure, requiring intervention. Other actions (A, B, D) follow correct infection control protocols.
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Which of the following tasks can the practical nurse (PN) safely assign to an experienced unlicensed assistive personnel (UAP)? Select all that apply.
- A. Ambulate an oxygen-dependent client to the bathroom
- B. Check pulse oximetry for a client with respiratory rate 12/min
- C. Instruct a client with pneumonia on usage of the incentive spirometer
- D. Provide oral hygiene to a client with chronic obstructive pulmonary disease (COPD)
- E. Turn and reposition a client with pneumonia
Correct Answer: A,B,D,E
Rationale: UAP can ambulate stable clients , check pulse oximetry , provide oral hygiene , and reposition clients . Instructing on incentive spirometry requires nursing judgment and is not delegable.
The nurse is planning a client care conference with the parents of a 3-year-old with newly diagnosed type 1 diabetes mellitus. What is the priority outcome for the caregivers?
- A. Demonstrating adequate coping skills
- B. Knowing how to keep blood sugars stable
- C. Understanding how to perform meal planning
- D. Understanding the need for periodic follow-up visits
Correct Answer: B
Rationale: The priority outcome for caregivers of a child with type 1 diabetes is knowing how to keep blood sugars stable , as this directly impacts the child's health and prevents complications. Coping , meal planning , and follow-up are important but secondary.
Which client condition is concerning and requires further nursing observation and intervention? Select all that apply.
- A. Client with asthma exacerbation and blood pressure is 150/90 mm Hg
- B. Client with spinal cord injury and blood pressure is 50/60 mm Hg
- C. Client with coronary artery disease on metoprolol, pulse is 62/min
- D. Elderly client with black stool; pulse is 112/min
- E. Neonate crying inconsolably at feeding time; pulse is 160/min
Correct Answer: B,D,E
Rationale: Concerning conditions include: spinal cord injury with hypotension suggesting neurogenic shock; black stool and tachycardia indicating possible GI bleeding; and inconsolable neonate with tachycardia suggesting distress. Asthma with hypertension and stable pulse on metoprolol are less urgent.
The client tells the nurse she is having trouble falling asleep. What initial nursing action is least appropriate?
- A. Asking the physician for a sleeping medication
- B. Offering the client a back rub
- C. Asking the client if she is concerned about something
- D. Repositioning the client
Correct Answer: A
Rationale: Requesting sleeping medication is premature and least appropriate without exploring non-pharmacologic interventions like back rubs, addressing concerns, or repositioning, which promote sleep naturally.
After passing a nasogastric (NG) tube in an adult, the nurse checks for proper placement by doing which of the following?
- A. Injecting air into the NG tube and listening with a stethoscope over the stomach for a 'swoosh'
- B. Putting the end of the NG tube in a glass of water and observing for bubbles
- C. Asking the client if the tube is comfortable
- D. Aspirating contents and checking the pH
Correct Answer: D
Rationale: Aspirating gastric contents and checking pH (typically 1-5 for stomach) is the most reliable method to confirm NG tube placement in the stomach. Air injection is less definitive, water bubbling is unsafe, and comfort does not confirm placement.