Nokea
The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to care for
- A. a client with Alzheimer’s requiring assistance with feeding.
- B. a client with osteoporosis complaining of burning on urination.
- C. a client with scleroderma receiving a tube feeding.
- D. a client with cancer who has Cheyne-Stokes respirations.
Correct Answer: A
Rationale: standard, unchanging procedure
You may also like to solve these questions
A client has increasing pain in both hands. On examination, the nurse notes that the metacarpophalangeal and proximal interphalangeal joints are enlarged and swollen, swanneck deformity is evident, and the fingers on both hands show ulnar deviation. These findings are consistent with which of the following disorders?
- A. Osteoarthritis
- B. Rheumatoid arthritis
- C. Gouty arthritis
- D. Psoriatic arthritis
Correct Answer: B
Rationale: Swanneck deformity, ulnar deviation, and swollen MCP/PIP joints are classic for rheumatoid arthritis (B). Osteoarthritis (A) affects distal joints, gout (C) causes tophi, and psoriatic arthritis (D) involves skin lesions.
A diagnosis of multiple sclerosis is often delayed because of the varied symptoms experienced by those affected with the disease. Which symptom is most common in those with multiple sclerosis?
- A. Resting tremors
- B. Double vision
- C. Flaccid paralysis
- D. Pill-rolling tremors
Correct Answer: B
Rationale: Double vision (diplopia) is a common early symptom of multiple sclerosis due to demyelination affecting cranial nerves, particularly the optic and oculomotor nerves.
The nurse is caring for a Muslim client who is recovering from an automobile accident and is unable to cleanse herself after a bowel movement. Which of the following should the nurse do to show respect for the woman's cultural and religious beliefs?
- A. Use the left hand to cleanse the client's rectal area.
- B. Ask a female family member to assist the client.
- C. Wear gloves when cleansing the client's rectal area.
- D. Ask the client's husband to assist the client.
Correct Answer: B
Rationale: In Islamic culture, hygiene after defecation is important, and female clients may prefer assistance from female family members (B) to maintain modesty. The left hand (A) is traditionally used by the client, not the nurse. Gloves (C) are standard but not cultural. The husband (D) may not be appropriate due to modesty.
The charge nurse considers both patient-related and staff-related factors when making daily assignments. All of the following are patient-related factors EXCEPT
- A. mechanical ventilation use.
- B. complex medication regimen.
- C. isolation precaution requirements.
- D. nurse-to-client ratio.
Correct Answer: D
Rationale: Nurse-to-client ratio is a staff-related factor, affecting workload distribution. Ventilation, medications, and isolation are patient-specific needs.
The nurse is caring for a client with pneumonia who is allergic to penicillin. Which antibiotic is safest to administer to this client?
- A. Cefazolin (Ancef)
- B. Amoxicillin
- C. Erythrocin (Erythromycin)
- D. Ceftriaxone (Rocephin)
Correct Answer: C
Rationale: Erythromycin is a macrolide, safe for penicillin-allergic clients, unlike cefazolin, amoxicillin, or ceftriaxone, which are beta-lactams with cross-reactivity risks.