Nokea
The unlicensed assistive personnel (UAP) reports to the nurse that during rounds a client has recently become pale. What is the nurse's first action?
- A. Activate the facility's emergency response system
- B. Ask the UAP to obtain a full set of vital signs
- C. Check on the client to collect further data
- D. Immediately notify the health care provider
Correct Answer: C
Rationale: Assessing the client directly (C) confirms the report and guides next steps. Activating emergency response (A), delegating vitals (B), or notifying the provider (D) is premature without assessment.
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The charge nurse observes a student nurse administering a tuberculin skin test using the intradermal route. Which action by the student nurse requires intervention and additional teaching from the charge nurse?
- A. Advances tip of needle through epidermis until the bevel is no longer visible under the skin
- B. Chooses a 1-mL tuberculin syringe with a 27-gauge, 1/4-inch needle; dons clean gloves
- C. Injects medication slowly while raising a small wheal (bleb) on the skin
- D. Inserts needle at a 10-degree angle almost parallel to the skin with the bevel up
Correct Answer: A
Rationale: Advancing until the bevel is invisible (A) is too deep for intradermal injection, requiring intervention. Syringe choice (B), wheal formation (C), and angle (D) are correct.
A client diagnosed with acute glomerulonephritis has pitting edema in the lower extremities, a blood pressure of 170/80 mm Hg, and proteinuria. When the practical nurse is assisting in the development of a care plan for this client, which measurement is the most accurate indicator of fluid loss or gain and should therefore be included in the plan?
- A. Blood pressure measurements
- B. Daily weight measurements
- C. Severity of pitting edema
- D. Strict intake and output measurements
Correct Answer: B
Rationale: Daily weights (B) are the most accurate for tracking fluid balance in glomerulonephritis. Blood pressure (A), edema (C), and intake/output (D) are less precise.
The nurse is caring for a client with schizophrenia. The client appears anxious and states, 'The voices are bad today; they sound so angry with me.' Which of the following responses would be most appropriate for the nurse to make?
- A. You should not listen to the voices.
- B. Remember that the voices are not real. Tell the voices to go away.
- C. What are the voices saying to you?
- D. That sounds frightening. Would you like medication to help you feel less anxious?
Correct Answer: D
Rationale: Acknowledging the client's fear and offering medication (D) is therapeutic and addresses anxiety. Dismissing voices (A, B) or probing content (C) may increase distress or reinforce delusions.
The practical nurse (PN) is assisting with care for a 1-day-old client who is irritable, feeding poorly, and only sleeping for very short intervals. The newborn's mother has been taking hydrocodone on a regular basis for several years. When collaborating with the registered nurse to develop the plan of care, which intervention should the PN include?
- A. Avoid giving the newborn a pacifier
- B. Position the newborn supine after feeding
- C. Stimulate the newborn with light regularly
- D. Swaddle and gently rock the newborn
Correct Answer: D
Rationale: Swaddling and rocking (D) soothe a newborn with neonatal abstinence syndrome due to maternal hydrocodone use. Pacifiers (A) are helpful, supine positioning (B) is for safety but not soothing, and stimulation (C) may worsen irritability.
A 56-year-old client who had a complete hysterectomy 8 months ago is admitted for opiate detoxification. The second day after admission, the client complains of abdominal cramping and sweating. What is the nurse's best response?
- A. Contact the gynecologist for details of the operation
- B. Suspect drug seeking and suggest the client take a walk around the unit
- C. Tell the client she is probably constipated and ask for an order for Milk of Magnesia
- D. Explain to the client that her symptoms are an expected physical response to detoxification and offer comfort medications as ordered
Correct Answer: D
Rationale: Abdominal cramping and sweating are withdrawal symptoms during opiate detoxification, requiring comfort measures and reassurance.