Nokea
The nurse practicing on a long-term care unit cares for a client with type 1 diabetes mellitus. Which action should the nurse assign to experienced unlicensed assistive personnel?
- A. Check the blood glucose before meals and report it to the nurse
- B. Instruct the client to cut toenails straight across and file any sharp edges
- C. Monitor the client for signs and symptoms of hypoglycemia
- D. Update the care plan to include client's preference for a nighttime diabetic snack
Correct Answer: A
Rationale: Checking blood glucose and reporting results is within UAP scope if trained. Teaching, monitoring for hypoglycemia, and updating care plans require nursing judgment and are outside UAP scope.
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The nurse is talking with the parent of a 2-year-old client who has a sunburn across the back and shoulders. Which of the following statements by the parent would indicate a correct understanding of sunburn care? Select all that apply.
- A. I will encourage my child to drink extra fluids.
- B. I will give my child aspirin to help relieve pain.
- C. I can allow my child to play outdoors with adequate sun protection.
- D. I can place cool compresses on my child's back to decrease discomfort
- E. I will apply hydrocortisone cream to the affected area and cover it with gauze dressings.
Correct Answer: A,C,D
Rationale: Extra fluids prevent dehydration, cool compresses soothe skin, and outdoor play with protection (sunscreen, clothing) is safe. Aspirin is avoided in children due to Reye's syndrome risk. Hydrocortisone isn't standard for sunburn; aloe or moisturizers are preferred.
A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect?
- A. Black, sticky stools
- B. Greasy, foul-smelling stools
- C. Stools mixed with blood and mucus
- D. Thin, 'ribbon-like' stools
Correct Answer: C
Rationale: Intussusception causes intestinal obstruction, often leading to 'currant jelly' stools (blood and mucus). Black, sticky stools suggest upper GI bleeding. Greasy stools indicate malabsorption. Ribbon-like stools suggest rectal narrowing.
Which nursing diagnosis is least likely to apply to the client admitted with a diagnosis of borderline personality disorder?
- A. Risk for self-injury
- B. Identity disturbance
- C. Self-esteem disturbance
- D. Sensory-perceptual alteration
Correct Answer: D
Rationale: Borderline personality disorder is characterized by self-injury, identity issues, and low self-esteem, making A, B, and C relevant. Sensory-perceptual alteration is more associated with psychotic disorders, so D is least likely.
A nurse is teaching a class for new parents at a local community center. The nurse would stress that what is most hazardous for an 8 month-old child?
- A. Riding in a car
- B. Falling off a bed
- C. An electrical outlet
- D. Eating peanuts
Correct Answer: D
Rationale: Eating peanuts. Asphyxiation due to foreign materials in the respiratory tract is the leading cause of death in children younger than 6 years of age.
The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
- A. Macaroni and cheese
- B. Shrimp with rice
- C. Turkey breast
- D. Spaghetti and meatballs
Correct Answer: C
Rationale: Turkey contains the least amount of fat and cholesterol. Cheese, shrimp, and beef should be avoided by the client on a low cholesterol, low fat diet; therefore, answers A, B, and D are incorrect.