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 caring for a client with Kawasaki disease. Which of the following actions would be a priority for the nurse to take?
- A. Monitor the client for gallop heart sounds and decreased urine output.
- B. Provide a quiet, nonstimulating, restful environment for the client.
- C. Apply cool compresses to the skin of the client's hands and feet.
- D. Offer the client soft foods and adequate amounts of clear liquids.
Correct Answer: B
Rationale: A quiet, restful environment reduces irritability and stress in Kawasaki disease, promoting recovery. Monitoring heart sounds/urine output is secondary, as cardiac complications are less immediate. Cool compresses and soft foods are less critical.
The nurse is explaining the effects of cocaine abuse to a pregnant client. Which of the following must the nurse understand as a basis for teaching?
- A. Cocaine use can cause fetal growth retardation
- B. The drug has been linked to neural tube defects
- C. Newborn withdrawal generally occurs immediately after birth
- D. Breast feeding promotes positive parenting behaviors
Correct Answer: A
Rationale: Cocaine is vasoconstrictive, and this effect in the placental vessels causes fetal growth retardation.
A client returns from surgery after having a suprapubic prostatectomy. Upon assessing the client, the nurse notes that his urine is bright red with many clots. Which of the following nursing actions is most appropriate?
- A. Check the client's vital signs and notify the physician.
- B. Check whether the continuous irrigation is working properly.
- C. Recognize that this is a normal finding after surgery and continue post-op care.
- D. Apply traction on the catheter and notify the physician.
Correct Answer: B
Rationale: Bright red urine with clots suggests a need to check the continuous bladder irrigation system to ensure it is functioning to prevent clot obstruction.
The nurse has reinforced teaching with a client who has anxiety and a new prescription for alprazolam. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I can continue to take my prescribed muscle relaxant as needed.
- B. I can omit the medication on days when I do not feel anxious.
- C. I should eliminate aged cheese and processed meats from my diet.
- D. I will discontinue the medication and notify my health care provider if I become pregnant.
Correct Answer: D
Rationale: Alprazolam is a benzodiazepine, and its use during pregnancy can pose risks to the fetus. Discontinuing and notifying the provider is critical. Muscle relaxants may enhance sedation, skipping doses disrupts therapeutic levels, and dietary restrictions like avoiding tyramine are not required for alprazolam.
Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
- A. 16 year-old who had an open reduction of a fractured wrist 10 hours ago
- B. 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
- C. 72 year-old recovering from surgery after a hip replacement 2 hours ago
- D. 75 year-old who is in skin traction prior to planned hip pinning surgery.
Correct Answer: C
Rationale: Look for the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first.