Nokea
The nurse observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?
- A. Praise the UAP for using standard precautions.
- B. Instruct the UAP to change gloves immediately.
- C. Request that an in-service program be scheduled on asepsis.
- D. Submit an adverse occurrence report to the unit manager.
Correct Answer: B
Rationale: Changing gloves prevents cross-contamination.
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During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?
- A. Secure an allergy bracelet around the client's wrist.
- B. Notify the dietary department of the client's fruit allergy.
- C. Send a list of medication allergies to the pharmacy.
- D. Place a latex-free supply cart outside the client's room.
Correct Answer: A
Rationale: Allergy bracelet prevents immediate exposure.
The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?
- A. Bowel incontinence.
- B. Impaired bed mobility.
- C. Fluid volume deficit.
- D. Caregiver role strain.
Correct Answer: C
Rationale: Dehydration from diarrhea is life-threatening.
While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?
- A. Unpleasant odor of the breath
- B. White patches on the mucosa.
- C. Gumline that has visibly receded.
- D. Discoloration of several teeth.
Correct Answer: B
Rationale: White patches suggest thrush requiring treatment.
The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize that the client is at greater risk for the development of which complication?
- A. Fibromyalgia
- B. Peptic ulcer disease.
- C. Hypertension
- D. Hypothyroidism.
Correct Answer: C
Rationale: OSA increases blood pressure via hypoxia.
A client is in the terminal stage of lung cancer. Outside the room, the client's spouse expresses to the nurse feelings of helplessness and a lack of hope for the future. How should the nurse respond?
- A. Offer comfort that healing can happen at any point in time.
- B. Offer strategies the spouse can use to provide comfort to the client.
- C. Suggest that the spouse go home for a while and get some sleep.
- D. Explain that the staff will strive to keep the client comfortable.
Correct Answer: D
Rationale: Reassurance about care addresses concerns.