Nokea
The nurse manager reviews tasks delegated to unlicensed assistive personnel (UAP). Which of the following tasks requires follow-up by the nurse manager?
- A. providing perineal care to a client with an indwelling urinary catheter
- B. performing range of motion activities
- C. reminding the client how to care for their long-term colostomy
- D. ambulating a client who requires a gait belt
Correct Answer: C
Rationale: Reminding a client about colostomy care (C) involves teaching, which is outside the UAP’s scope and requires follow-up. Perineal care (A), range of motion (B), and ambulation with a gait belt (D) are appropriate UAP tasks.
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The nurse in a clinic is triaging clients. Which of the following clients should the nurse see first?
- A. A 17-year-old complaining of abdominal cramping with moderate bloody vaginal discharge
- B. A 25-year-old primigravida reporting blurred vision.
- C. A 50-year-old menopausal client expelling dark red blood clots.
- D. A 70-year-old client who states her uterus is going to 'fall out.'
Correct Answer: B
Rationale: Blurred vision in a 25-year-old primigravida (B) suggests preeclampsia, a life-threatening emergency requiring immediate assessment. Abdominal cramping with bleeding (A), menopausal clotting (C), and uterine prolapse (D) are less urgent, though they require follow-up.
The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks would be appropriate for the nurse to assign to UAP? Select all that apply.
- A. Transport a client with an ankle fracture to radiology.
- B. Calculate and record a client's oral intake for the shift.
- C. Ambulate a client who is eight hours post-laparoscopic surgery.
- D. Assist a client with multiple sclerosis in performing oral care.
- E. Obtain a urine culture and sensitivity sample from an indwelling urethral catheter.
Correct Answer: A, C, D
Rationale: UAPs can transport stable clients (A), ambulate post-surgical clients (C), and assist with oral care (D). Calculating intake (B) requires clinical judgment, and obtaining a urine culture (E) involves sterile technique, both RN/LPN tasks.
The nurse in the emergency department is caring for a client who sustained multiple rib fractures and a nasal fracture from a motor vehicle crash. Which assessment finding requires immediate follow-up?
- A. shallow respirations
- B. chest pain with repositioning
- C. bruising on the chest
- D. vomiting
Correct Answer: A
Rationale: Shallow respirations (A) in a client with rib fractures suggest impaired ventilation, risking hypoxia or pneumothorax, requiring immediate follow-up. Chest pain (B), bruising (C), and vomiting (D) are expected but less urgent.
The nurse is caring for assigned clients. The nurse should first assess the client
- A. with pericarditis who reports increasing chest pain while laying down flat.
- B. with cystic fibrosis who has a temperature of 102.5°F (39.2°C).
- C. who has rhinosinusitis and is reporting facial pain that increases when bending forward.
- D. who has hypertrophic cardiomyopathy and has dyspnea after ambulating in the hallway.
Correct Answer: A
Rationale: Increasing chest pain when lying flat in pericarditis (A) suggests worsening pericardial effusion, a life-threatening condition requiring immediate assessment. Fever in cystic fibrosis (B), sinusitis pain (C), and dyspnea in cardiomyopathy (D) are less urgent.
The charge nurse is planning patient care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following patients would be most appropriate to assign to the LPN?
- A. admitted with acute compartment syndrome awaiting emergency surgery.
- B. with cystic fibrosis who needs an early morning sputum sample collection.
- C. with acute respiratory failure receiving high-flow oxygen therapy.
- D. sepsis requiring multiple intravenous (IV) antibiotics and initiation of vasopressors.
Correct Answer: B
Rationale: Collecting a sputum sample for cystic fibrosis (B) is a stable, routine task within the LPN’s scope. Compartment syndrome (A), respiratory failure (C), and sepsis with vasopressors (D) require RN assessment and management due to their critical nature.