Nokea
The nurse is working with an unlicensed assistive personnel (UAP). In planning the morning's care, which tasks can the nurse delegate to the UAP? Select all that apply.
- A. feeding a client who has lost the use of his hands
- B. starting an IV in a confused client who pulled her IV out
- C. assisting a stable and alert client up to the bedside commode
- D. checking an apical pulse in a client prior to administering digoxin
- E. ambulating a client in the hall for the first time since surgery to repair a fractured T5 vertebra
Correct Answer: A, C
Rationale: Feeding and assisting a stable client to the commode are within the UAP’s scope, while starting an IV, checking an apical pulse, and ambulating a post-surgical client require nursing judgment.
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The nurse has given instructions on pursed-lip breathing to a client with COPD. Which statement by the client would indicate effective teaching?
- A. I should inhale through my mouth.'
- B. I should tighten my abdominal muscles with inhalation.'
- C. I should contract my abdominal muscles with exhalation.'
- D. I should make inhalation twice as long as exhalation.'
Correct Answer: C
Rationale: Pursed-lip breathing involves inhaling through the nose and exhaling slowly through pursed lips, which may involve contracting abdominal muscles to assist with exhalation, prolonging exhalation to reduce air trapping in COPD.
The nurse must administer in one syringe a combined dose of two different insulins from two vials. Place the steps (Roman numerals) in the correct order.
- A. Cleanse tops of vials.
- B. Inject air into vial 1.
- C. Withdraw medication from vial 1.
- D. Change needles.
- E. Withdraw medication from vial 2.
- F. Inject air into vial 2.
Correct Answer: A,B,F,C,E
Rationale: The correct order is: Cleanse vials (I), inject air into vial 1 (II), inject air into vial 2 (VI), withdraw from vial 1 (III), withdraw from vial 2 (V). Changing needles (IV) is not standard.
In many cultures, pregnancy is viewed as a natural rather than a medical condition. How does this affect prenatal care?
- A. Pregnant women often seek prenatal care later and less frequently.
- B. These views have little effect on prenatal care.
- C. Pregnant women believe prenatal care is harmful to the fetus.
- D. These views often result in increased rates of fetal mortality.
Correct Answer: A
Rationale: Viewing pregnancy as natural (A) often leads to delayed or less frequent prenatal care, impacting monitoring. Harmful beliefs (C) or increased mortality (D) are not directly implied.
The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client's most appropriate priority nursing diagnosis?
- A. Alteration in cerebral tissue perfusion
- B. Fluid volume deficit
- C. Ineffective airway clearance
- D. Alteration in sensory perception
Correct Answer: B
Rationale: The vital signs indicate hypovolemic shock, making fluid volume deficit the priority nursing diagnosis.
A client with rheumatoid arthritis tells the nurse that she is having increasing difficulty cooking, cleaning, and attending to activities of daily living. Which of the following referrals is the most appropriate?
- A. Occupational therapist.
- B. Physical therapist.
- C. Home health agency.
- D. Assisted-living facility.
Correct Answer: A
Rationale: An occupational therapist (A) helps clients with rheumatoid arthritis adapt to difficulties with daily activities through adaptive techniques and equipment. Physical therapy (B), home health (C), or assisted living (D) may be secondary.