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The unlicensed assistive personnel notifies the charge nurse that the client is reporting feeling short of breath. What should the charge nurse do first?
- A. Activate a rapid response team
- B. Ask the unlicensed assistive personnel to take vital signs and report back
- C. Direct the client's primary nurse to examine the client
- D. Personally go and auscultate the client's lungs
Correct Answer: C
Rationale: Directing the primary nurse to assess the client ensures a timely, qualified evaluation of shortness of breath, a potentially serious symptom.
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The nurse is assigning client care tasks to unlicensed assistive personnel. Which statement by the nurse is appropriate?
- A. I need you to take vital signs on all clients in rooms 1 through 10 this morning
- B. Mrs. Jones fell out of bed during the night while walking to the commode. Please monitor her closely.
- C. Please ensure that Mr. Garcia in room 8 ambulates several times.
- D. Please take Mr. Wu's vital signs in 10 minutes and let me know if his systolic blood pressure is <100.
Correct Answer: A
Rationale: Assigning vital signs for multiple clients is clear, specific, and within the UAP's scope of practice, ensuring safe delegation.
The nurse is caring for a client whose peritoneal dialysis is beginning to exhibit insufficient outflow. What actions should the nurse perform initially? Select all that apply.
- A. Check the client for abdominal distention and constipation
- B. Examine the catheter for kinks and obstructions
- C. Contact the client's health care provider
- D. Place the client in a side-lying position
- E. Flush the tubing with dialysate
Correct Answer: A,B,D
Rationale: Checking for distention/constipation (A), examining for catheter issues (B), and repositioning to a side-lying position (D) address common causes of outflow issues non-invasively.
The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which findings as expected neurological changes for the client with a concussion? Select all that apply.
- A. Amnesia
- B. Asymmetrical pupillary constriction
- C. Brief loss of consciousness
- D. Headache
- E. Loss of vision
Correct Answer: A,C,D
Rationale: Amnesia (A), brief loss of consciousness (C), and headache (D) are common symptoms of concussion due to temporary brain dysfunction.
The parent of a 6-year-old calls the nurse and reports that the child was playing outside in the snow and the child's feet now appear red and swollen. What is the best response by the nurse?
- A. Bring the child to the health care provider's (HCP) office immediately.
- B. Give your child something warm to drink.
- C. Massage the child's feet gently until they warm up.
- D. Place the child's feet in warm water immediately.
Correct Answer: D
Rationale: Red and swollen feet suggest frostbite or cold injury. Immersing the feet in warm (not hot) water is the safest and most effective way to rewarm the tissue and prevent further damage.
A client with a partial bowel obstruction has a Miller-Abbot tube inserted to decompress the bowel. While the tube is in place, the nurse should give priority to:
- A. Using only normal saline to irrigate the tube every 4 hours
- B. Advancing the tube 3-4 inches as ordered by the physician
- C. Changing the tape securing the tube to the client's face daily to prevent skin breakdown
- D. Attaching the tube to high constant suction
Correct Answer: C
Rationale: Preventing skin breakdown by changing the tape daily is critical to avoid tissue damage around the insertion site. Irrigation and suction settings depend on physician orders, and advancing the tube is not a nursing priority without specific instructions.