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The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?
- A. Assign an RN to provide total care of the client
- B. Assign a nursing assistant to help the client with self-care activities
- C. Delegate complete care to an unlicensed assistive personnel
- D. Supervise a nursing assistant for skin care
Correct Answer: D
Rationale: Supervise a nursing assistant for skin care. The nursing assistant can inspect the skin while giving hygiene care, but the nurse should supervise skin care since assessment and analysis are needed.
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A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with
- A. a Dopamine drip IV with vital signs monitored every 5 minutes
- B. a myocardial infarction that is free from pain and dysrhythmias
- C. a tracheotomy of 24 hours in some respiratory distress
- D. a pacemaker inserted this morning with intermittent capture
Correct Answer: B
Rationale: This client is the most stable with minimal risk of complications or instability. The nurse can utilize basic nursing skills to care for this client, making it suitable for a nurse from another unit.
Which of these clients would be the highest priority for the nurse to assign to a private room?
- A. A client with a new diagnosis of tuberculosis
- B. A client with a urinary tract infection
- C. A client post-appendectomy with a surgical site infection
- D. A client with seasonal influenza
Correct Answer: A
Rationale: A client with tuberculosis requires a private room with negative pressure to prevent airborne transmission of the disease.
The client had a THR. The nurse is discussing home modifications with the client's son. Which modifications should the nurse recommend? Select all that apply.
- A. Pad bed side rails.
- B. Install safety bars around the toilet and shower.
- C. Install an elevated toilet seat in the bathroom.
- D. Plan for the client's bed to be in a main floor room.
- E. Use a nonskid bathmat in the bathtub for the client's daily bath.
- F. Remove scatter rugs and secure electrical cords against baseboards.
Correct Answer: B,C,D,F
Rationale: B: Safety bars aid mobility. C: Elevated toilet seat prevents excessive hip flexion. D: Main floor bedroom avoids stairs. F: Removing rugs and cords prevents tripping. A is unnecessary, and E is incorrect as tub baths are avoided post-THR.
The new NA is caring for the client who is at risk for a fall. Which statement by the nurse to the new NA is most important?
- A. "Remind the client to call for assistance before getting out of bed."
- B. "Clip the call light to the bedcovers so the client can find it easily."
- C. "Be sure the bed is in the lowest position when you leave the room."
- D. "Check that you have all four side rails up after you provide care."
Correct Answer: C
Rationale: Ensuring the bed is in the lowest position is critical to minimize injury from a fall, which poses a greater risk than other options. Four side rails (D) are considered a restraint and should be avoided.
A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action?
- A. Discharge the client from home health care because of noncompliance
- B. Notify the provider of the client's failure to follow prescribed diet
- C. Discuss diet with the client to learn the reasons for not following the diet
- D. Make a referral to Meals-on-Wheels
Correct Answer: C
Rationale: Discuss diet with the client to learn the reasons for not following the diet. When new problems are identified, it is important for the nurse to collect accurate assessment data. Before reporting findings to the provider, it is best to have a complete understanding of the client's behavior and feelings as a basis for future teaching and intervention.