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The nurse suspects that a child may have ingested a caustic substance. Which comment by the child would be of greatest concern to the nurse?
- A. Ask the child if the mouth is burning or throat pain is present.'
- B. I feel sleepy and my stomach hurts.'
- C. My tongue feels funny and I’m thirsty.'
- D. Has the child had vomiting, diarrhea or stomach cramps?'
Correct Answer: A
Rationale: Local irritation of tissues indicates a corrosive poisoning. Burning in the mouth or throat pain suggests ingestion of a caustic substance, requiring immediate attention.
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The client with a left-sided weakness is to be discharged to home, where the client has an electrical bed. In preparation for discharge, the nurse assesses the client's ability to get out of bed independently- Which client actions indicate that further instruction is needed? Select all that apply.
- A. Places the bed in the lowest position
- B. Raises the head of the bed (HOB)
- C. Rolls onto the left side
- D. Pushes against the mattress with the weak elbow and stronger hand to rise to a sitting position
- E. Slides legs off the bed while pushing against the mattress to raise the body off the bed
- F. Once in a sitting position, sits at the edge of the bed for a few minutes before standing
Correct Answer: C,D
Rationale: C: Rolling onto the weaker left side is incorrect; the client should roll onto the stronger right side to maximize strength and stability. D: Using the weak elbow instead of the stronger elbow and hand to push off increases the risk of injury and instability.
A power outage occurs at a hospital, and a backup generator supplying power to a telemetry unit fails. After obtaining a flashlight, what is the nurse's next best action?
- A. Call the nursing supervisor
- B. Assess the most critically ill clients
- C. Obtain oxygen tanks for clients on oxygen
- D. Delegate which clients the NA should monitor
Correct Answer: C
Rationale: Obtaining oxygen tanks is the priority, as room oxygen sources fail during a power outage, and clients on oxygen are at immediate risk.
A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia (MRSA). What type of isolation is most appropriate for this client?
- A. Reverse
- B. Airborne
- C. Standard precautions
- D. Contact
Correct Answer: D
Rationale: Contact precautions or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected.
An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?
- A. How long have you been a UAP and what units you have worked on?
- B. What type of care do you give on the surgical unit and what ages of clients?
- C. What is your comfort level in caring for children and at what ages?
- D. Have you reviewed the list of expected skills you might need on this unit?
Correct Answer: D
Rationale: The UAP must be competent to accept the delegated task. Review of skills needed versus level of performance is the most efficient and effective way to determine this.
The nurse is teaching the client with a latex allergy about home and personal safety. Which information should the nurse emphasize? Select all that apply.
- A. Remove items in the home made from synthetic materials.
- B. Keep emergency telephone numbers readily accessible.
- C. Have someone remove any latex balloons and rubber bands.
- D. Avoid foods such as kiwi, bananas, avocados, and chestnuts.
- E. Certain plants, such as poinsettia plants, help remove allergens.
Correct Answer: B,C,D
Rationale: B: Emergency numbers are critical for anaphylaxis. C: Latex items like balloons and rubber bands must be removed to avoid exposure. D: Certain foods can trigger cross-reactive allergic reactions. A and E are incorrect as synthetic materials are safe, and poinsettias can cause reactions.