Nokea
The nurse is planning client care assignments. Which task should be delegated to the unlicensed assistive personnel (UAP)?
- A. The initial ambulation of a client following a laparoscopic hernia repair.
- B. Feed a client who has dysphagia.
- C. Applying sequential compression devices to a client’s lower extremities.
- D. Calling in prescriptions to the local pharmacy for a client ready for discharge.
Correct Answer: C
Rationale: Applying sequential compression devices (C) is a non-clinical task within the UAP’s scope. Initial ambulation (A), feeding with dysphagia (B), and calling prescriptions (D) require clinical judgment or RN/LPN skills due to risk or complexity.
You may also like to solve these questions
The nurse arrives to assist victims following an earthquake. Which victim would the nurse recognize as the highest priority for immediate treatment?
- A. 74-year-old with several heavily bleeding wounds who is lethargic and pale.
- B. 37-year-old who appears anxious, tired, and using neck muscles to breathe.
- C. 16-year-old who is confused, holding her head, and complaining of nausea.
- D. 65-year-old who rates his pain at 10/10 and is guarding his right leg.
Correct Answer: A
Rationale: A 74-year-old with heavy bleeding, lethargy, and pallor (A) indicates hemorrhagic shock, a life-threatening condition requiring immediate treatment. Respiratory distress (B), confusion with nausea (C), and severe pain (D) are serious but less urgent than uncontrolled bleeding.
The nurse is planning to interview a client interested in establishing care with a primary healthcare provider (PHCP). The nurse should initially
- A. obtain the client's vital signs.
- B. identify the client's chief complaint.
- C. provide a private area for the interview.
- D. inquire about the client's allergies.
Correct Answer: C
Rationale: Providing a private area (C) ensures confidentiality and comfort, the initial step for an interview. Chief complaint (B), allergies (D), and vital signs (A) follow after establishing privacy.
The nurse plans care for a client with a vancomycin-resistant enterococcus (VRE) infection. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Place gowns and gloves outside of the client’s room
- B. Educate the client and family members on ways to prevent transmission of VRE
- C. Affix a droplet precautions sign on the client’s door
- D. Validate the client’s understanding on hand hygiene
Correct Answer: A
Rationale: Placing gowns and gloves outside the room (A) is a non-clinical task within the UAP’s scope. Education (B), signage for droplet precautions (C, incorrect for VRE), and validating understanding (D) require clinical judgment and are RN/LPN responsibilities.
The nurse is triaging clients in the emergency department (ED). Which client should the nurse triage as emergent? A client
- A. reporting pleuritic chest pain with a productive cough.
- B. who is pregnant and reporting intermittent nausea and vomiting.
- C. who has an isolated area of reddened vesicles and malaise.
- D. with sudden onset of ataxia and dysarthria.
Correct Answer: D
Rationale: Sudden ataxia and dysarthria (D) suggest a stroke, an emergent condition requiring immediate triage for time-sensitive intervention. Pleuritic cough (A), pregnancy nausea (B), and vesicles/malaise (C) are less urgent.
The nurse is reviewing laboratory data for assigned clients. Which laboratory result requires immediate follow-up with the primary healthcare provider (PHCP)?
- A. Elevated amylase result in a client diagnosed with acute pancreatitis
- B. Elevated white blood cell (WBC) count in a client with an infected leg wound.
- C. Urinalysis positive for leukocytes and nitrites for a client receiving chemotherapy
- D. Serum glucose of 235 mg/dL (13.05 mmol/L) [70-110 mg/dL; 4-6 mmol/L] in a client with diabetes mellitus (type one)
Correct Answer: C
Rationale: Leukocytes and nitrites in urinalysis for a chemotherapy client (C) indicate a possible urinary tract infection, critical due to immunosuppression. Elevated amylase (A) and WBC (B) are expected, and glucose of 235 (D) is elevated but less urgent.