Nokea
The unlicensed assistive personnel (UAP) reported an intake of 1,000 mL and a urinary output of 1,500 mL for a client who received a thiazide diuretic this morning. Which nursing task could the nurse delegate to the nursing assistant?
- A. Instruct the UAP to restrict the client's fluid intake.
- B. Request the UAP to insert a Foley catheter with an urometer.
- C. Tell the UAP urinary outputs are no longer needed.
- D. Ask the UAP to document fluids on the bedside I & O record.
Correct Answer: D
Rationale: Documenting I&O is within UAP scope; fluid restriction, catheter insertion, or discontinuing monitoring require nursing judgment.
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An elderly adult is scheduled for repair of a fractured femur this morning. The nurse goes in to administer the preoperative medication of Demerol 75 mg and atropine 0.4 mg IM. The client asks the nurse if he should take his eye drops before surgery. What is the best initial response for the nurse to make?
- A. You can take them when you get back from surgery.
- B. I'll give them to you now.
- C. Let me check with your physician.
- D. What kind of eye drops are you taking?
Correct Answer: D
Rationale: Knowing the type of eye drops (e.g., for glaucoma or infection) determines if they are critical pre-surgery, guiding further action.
The nurse is caring for an elderly client who is eight (8) hours postoperative hip replacement and is reporting incisional pain. Which intervention is priority for this client?
- A. Assist the client to sit in the bedside chair.
- B. Initiate pain medication at the lowest dose.
- C. Assess the client's pupil size and accommodation.
- D. Monitor the client's urinary output hourly.
Correct Answer: B
Rationale: Pain management is the priority post-op to promote recovery and comfort; lowest dose minimizes side effects in the elderly. Sitting, pupil assessment, or urine output are secondary.
The health care provider orders an IV aminophylline infusion at 30 mg/hr. The pharmacy sends a 1,000 ml bag of D5W containing 500 mg of aminophylline. In order to administer 30 mg per hour, the RN will set the infusion rate at:
- A. 20 ml per hour
- B. 30 ml per hour
- C. 50 ml per hour
- D. 60 ml per hour
Correct Answer: D
Rationale: 60 ml per hour. Using the ratio method to calculate infusion rate: mg to be given (30) : ml to be infused (X) :: mg available (500) : ml of solution (1,000). Solve for X by cross-multiplying: 30 × 1,000 = 500 × X, 30,000 = 500X, X = 30,000 / 500, X = 60 ml per hour.
The client is receiving a loop diuretic for congestive heart failure. Which medication would the nurse expect the client to be receiving while taking this medication?
- A. A potassium supplement.
- B. A cardiac glycoside.
- C. An ACE inhibitor.
- D. A potassium cation.
Correct Answer: A
Rationale: Loop diuretics like furosemide cause potassium loss; supplements prevent hypokalemia, a common need in CHF.
The client in the emergency department requires sutures for a laceration on the left leg. Which information is most pertinent prior to suturing the wound?
- A. The client tells the nurse she has never had sutures.
- B. The spouse refuses to leave the room during suturing.
- C. The client shares she is scared of needles.
- D. The client reports hives after having dental surgery.
Correct Answer: D
Rationale: Hives post-dental surgery suggest a possible local anesthetic allergy, critical to know before suturing to avoid anaphylaxis.