Nokea
The unlicensed assistive personnel (UAP) reports to the nurse that a male client with fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the nurse implement?
- A. Ask the client why he does not want to be weighed.
- B. Instruct the UAP to weigh the client using a bed scale.
- C. Direct the UAP to delay weighing the client until later.
- D. Document that the client refused daily weights.
Correct Answer: B
Rationale: Using a bed scale accommodates the client's condition, ensuring accurate weight measurement without discomfort. Asking why, delaying, or documenting refusal do not address the need for timely data to monitor fluid status.
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The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take?
- A. Notify the healthcare provider.
- B. Monitor for signs of bleeding.
- C. Complete an adverse occurrence report.
- D. Obtain blood for coagulation studies.
Correct Answer: A
Rationale: Notifying the healthcare provider ensures prompt intervention to reverse anticoagulation and prevent bleeding. Monitoring, reporting, and testing are important but follow provider notification.
Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?
- A. A practical nurse is assigned to transport a postoperative client to the rehabilitation unit.
- B. A practical nurse (PN) is assigned to monitor the blood pressure of a client with hypertension.
- C. A graduate nurse is assigned to obtain a unit of packed red blood cells from the blood bank.
- D. An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction.
Correct Answer: D
Rationale: Checking for fecal impaction is beyond the UAP's scope, risking client injury. The other assignments (transport, BP monitoring, blood retrieval) are within the respective staff's competencies.
The home health aide caring for a home bound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?
- A. Listen for the presence of bowel sounds.
- B. Teach the client about foods high in fiber.
- C. Administer a prescribed dose of a laxative.
- D. Assist the client in drinking warm prune juice.
Correct Answer: D
Rationale: Assisting with drinking warm prune juice is within the aide's scope and promotes natural relief of constipation. Listening for bowel sounds, teaching about fiber, and administering laxatives require nursing skills and are beyond the aide's role.
A fire is reported in the kitchen on the first floor of a three-floor community hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. Which intervention should the charge nurse implement?
- A. Instruct unlicensed assistive personnel (UAPs) to transfer all non-ambulatory clients via wheelchairs.
- B. Instruct the nursing staff to evacuate ambulatory clients to the nearest fire exits.
- C. Shut all doors to client rooms and tell everyone to stay in their rooms until the fire department arrives.
- D. Announce in a calm voice that all visitors should proceed immediately to the first floor via the service elevators.
Correct Answer: C
Rationale: Shutting doors and keeping everyone in rooms follows the RACE protocol (Rescue, Alarm, Contain, Extinguish), containing the fire and protecting from smoke. Evacuating clients or using elevators during a fire risks exposure to danger.
After reviewing the morning laboratory findings for four clients, which client should the nurse follow up with first? Reference Range: International Normalized Ratio [0.8 to 1.1], Blood Glucose 74 to 106 mg/dL (4.1 to 5.9 mmol/L)], Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)], Brain Natriuretic Peptide (BNP) [less than 100 pg/mL (less than 100 ng/L)]
- A. The brain natriuretic peptide (BNP) assay for a client with shortness of breath after a myocardial infarction (MI) increases to 1000 pg/mL (1000 ng/L).
- B. The international normalized ratio (INR) for a client who is receiving warfarin therapy increases to 2.5.
- C. The serum glucose level for a client receiving corticosteroids increases to 150 mg/dL (8.3 mmol/L).
- D. The potassium level for a client scheduled for renal dialysis increases to 5 mEq/L(5 mmol/L).
Correct Answer: A
Rationale: A BNP of 1000 pg/mL indicates severe heart failure, requiring urgent interventions like oxygen and diuretics. The INR is therapeutic, glucose is mildly elevated, and potassium is normal, making these less urgent.