Nokea
The nurse observes the certified nursing assistant doing all of the following. Which action needs correction?
- A. Changing the dressing of a client with an abdominal wound
- B. Asking a standing client to sit down while vital signs are taken
- C. Emptying a urine drainage bag from the tube at the bottom
- D. Changing water in the middle of a bed bath
Correct Answer: A
Rationale: Changing dressings requires nursing judgment and sterile technique, outside a CNA's scope. Other actions are within their role.
You may also like to solve these questions
A client has a total laryngectomy with a permanent tracheostomy.
Which of the following would be necessary for the nurse to consider regarding the client's nutrition?
- A. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented.
- B. The client will be unable to maintain any PO intake as long as he has a tracheotomy in place.
- C. Nutritional and/or gastric feedings will not be attempted for approximately three weeks to decrease the incidence of aspiration.
- D. Since the client is dependent on the ventilator, nutritional intake will be delayed.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-tube feedings frequently started as the initial nutritional intake; prevents trauma to suture area (2) although the client has permanent tracheotomy, will be able to eat normally after area has healed (3) nutritional intake will begin when bowel sounds return and client can tolerate intake (4) client is not dependent on ventilator
A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to
- A. Convince the client that the hospital staff is trying to help
- B. Help the client to enter into group recreational activities
- C. Provide interactions to help the client learn to trust staff
- D. Arrange the environment to limit the client's contact with other clients
Correct Answer: C
Rationale: Provide interactions to help the client learn to trust staff. Establishing trust helps clients feel safer and facilitates a therapeutic alliance between staff and client.
What is the most important consideration when teaching parents how to reduce risks in the home?
- A. Age and knowledge level of the parents
- B. Proximity to emergency services
- C. Number of children in the home
- D. Age of children in the home
Correct Answer: D
Rationale: Age of children in the home. Safety measures must be tailored to the developmental stage of the children.
Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take?
- A. Record the information on the chart
- B. Give information about advance directives
- C. Assume that this client wishes a full code
- D. Refer this issue to the unit secretary
Correct Answer: B
Rationale: For each admission, nurses should request a copy of the current advance directive. If there is none, the nurse must offer information about what an advance directive implies. It is then the client's choice to sign it.
The nurse anticipates that for a family who practices Chinese medicine the priority therapeutic goal would be to
- A. achieve harmony
- B. maintain a balance of energy
- C. respect life
- D. restore yin and yang
Correct Answer: D
Rationale: For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang.