Nokea
The RN is making assignments for the day. Which one of the following duties can be assigned to the unlicensed assistive personnel?
- A. Notifying the physician of an abnormal lab value
- B. Providing routine catheter care with soap and water
- C. Administering two aspirin to a client with a headache
- D. Setting the rate of an infusion of normal saline
Correct Answer: B
Rationale: Unlicensed assistive personnel can perform routine catheter care, a non-invasive task within their scope.
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A client is transferred to the intensive care unit following a conornary artery bypass graft. Which one of the post-surgical assessments should be reported to the physician?
- A. Urine output of 50 ml in the past hour
- B. Temperature of 99°F
- C. Strong pedal pulses bilaterally
- D. Central venous pressure 15 mmHâ‚‚O
Correct Answer: D
Rationale: A central venous pressure of 15 mmHâ‚‚O is elevated, indicating potential fluid overload or cardiac issues, requiring reporting.
The nurse is assessing a client with suspected meningitis. Which of the following findings would the nurse expect?
- A. Positive Kernig’s sign.
- B. Hypothermia.
- C. Soft, non-tender neck.
- D. Decreased level of consciousness.
Correct Answer: A
Rationale: positive Kernig’s sign (pain and resistance on leg extension) is a classic finding in meningitis
The nurse is caring for a client with a wound that presents with full-thickness tissue loss and eschar covering the wound bed. The nurse would record this wound as which stage?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
- E. unstageable
Correct Answer: E
Rationale: A wound with eschar covering the bed is unstageable because the depth cannot be assessed until the eschar is removed.
The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis?
- A. A weight loss of 10 pounds in 2 weeks
- B. Complaints of numbness and tingling in the extremities
- C. A red, beefy tongue
- D. A hemoglobin level of 12.0 gm/dL
Correct Answer: C
Rationale: A red, beefy tongue is a classic sign of pernicious anemia due to vitamin B12 deficiency affecting mucosal tissues.
A client is receiving end-of-life care and tells the nurse that he has not always lived the way he should have or treated his children well. Which of the following responses is the most appropriate?
- A. What kinds of things have you done?'
- B. There are things that you regret.'
- C. I'm sure those things don't matter anymore.'
- D. It's not too late to ask for forgiveness.'
Correct Answer: B
Rationale: Reflecting that the client has regrets (B) is empathetic and opens further discussion without judgment. Asking for details (A), dismissing concerns (C), or suggesting forgiveness (D) may not be appropriate.