Nokea
The nurse is working with unlicensed assistive personnel (UAP). Which task can the nurse safely assign to UAP?
- A. Assisting a 2-day postoperative hip arthroplasty client with morning care
- B. Collecting a urine specimen for culture and sensitivity from a client with a Foley catheter
- C. Irrigating colostomy of a 2-day postoperative colostomy client who is stable
- D. Refilling the empty enteral feeding container with tube feeding
Correct Answer: B
Rationale: Collecting a urine specimen from a Foley catheter is within the UAP's scope, as it involves a straightforward procedure with proper training. Colostomy irrigation and refilling enteral feeding containers require nursing judgment and are not safe for UAP to perform.
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The nurse in the outpatient mental health clinic is evaluating the effectiveness of the treatment regimen for a client with dependent personality disorder. Which of the following statements by the client would indicate that the treatment regimen has been effective?
- A. I took the bus here today because my parents could not drive me.
- B. I appreciate all the time you have spent trying to help me feel better.
- C. I know I am not good at my job because I made a mistake at work today.
- D. I plan to stay with my cousin while my parents go away on vacation next week.
Correct Answer: A
Rationale: Clients with dependent personality disorder have a persistent and extreme need to be taken care of that manifests as submissive and clinging behaviors and fear of separation. Additional characteristics of dependent personality disorder may include:• Difficulty in making day-to-day decisions • An excessive need for advice, reassurance, and nurturing from others • Lack of self-confidence or fear of doing things independently • Fear of confrontation or expressing disagreement with others • Feelings of helplessness and anxiety when alone or fear of being unable to take care of oneself The ability to make decisions about and carry out daily activities without assistance (eg, planning alternate transportation) indicate that the treatment plan has been effective
The nurse enters the room of an adult who is having a grand mal seizure. Which initial action is appropriate?
- A. Put a padded tongue blade in the client's mouth.
- B. Restrain the client.
- C. Turn the client's head to the side.
- D. Call the physician immediately.
Correct Answer: C
Rationale: Turning the head to the side during a seizure prevents airway obstruction by saliva or vomit, prioritizing safety, unlike tongue blades (risk injury), restraints, or immediate physician calls.
The nurse is caring for several clients who have ostomies. Which client will have the most wellformed drainage? The client whose colostomy is in the:
- A. ileum.
- B. ascending colon.
- C. transverse colon.
- D. descending colon.
Correct Answer: D
Rationale: The descending colon absorbs more water, producing well-formed, solid stool compared to the ileum (liquid), ascending colon (semi-liquid), or transverse colon (semi-formed).
A chemical reaction between drugs prior to their administration or absorption is known as:
- A. a drug incompatibility.
- B. a side effect.
- C. an adverse event.
- D. an allergic response.
Correct Answer: A
Rationale: Drug incompatibility refers to chemical reactions between drugs before administration, like precipitation in IV lines. Side effects, adverse events, and allergic responses occur post-administration. Pharmacological Therapies
An adult is admitted to the hospital with several days of vomiting and diarrhea. Admitting data show RBC level of 4.2 million/mm³ and hematocrit of 54%. What is the best interpretation of these data?
- A. The client may have internal bleeding.
- B. The client is probably dehydrated.
- C. These are normal findings.
- D. The client is anemic.
Correct Answer: B
Rationale: Elevated hematocrit (normal: 36-46% for females, 41-53% for males) with normal RBC suggests hemoconcentration from dehydration due to fluid loss from vomiting and diarrhea.