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What is the best advice the nurse can offer the nursing assistant?
- A. Rinse your latex gloves with running tap water before putting them on.
- B. Apply a petroleum ointment to both hands before putting on latex gloves.
- C. Don't wear gloves, but wash your hands vigorously with alcohol after client contact.
- D. Wear two pairs of vinyl gloves when there's a potential for contact with body fluids.
Correct Answer: D
Rationale: Vinyl gloves avoid latex exposure while maintaining protection.
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The nurse is caring for a client who has developed stage IV pressure ulcers on the left trochanter and coccyx. Which collaborative problem has the highest priority?
- A. Impaired cognition.
- B. Altered nutrition.
- C. Self-care deficit.
- D. Altered coping.
Correct Answer: B
Rationale: Altered nutrition is critical in stage IV ulcers to support wound healing. Cognition, self-care, and coping are secondary in advanced wounds.
A 28-year-old man received severe burns of the chest, abdomen, back, legs, and hands when the house caught fire. In the emergency room, a nasogastric tube was inserted, and the client was ordered NPO. What is the primary reason for the nurse to keep this client NPO?
- A. To prevent the deadly complication of aspiration
- B. To make the client more comfortable
- C. To help prevent paralytic ileus
- D. To help prevent excessive fluid loss
Correct Answer: C
Rationale: Severe burns predispose clients to paralytic ileus due to stress and fluid shifts, so keeping the client NPO prevents complications until bowel function returns.
When the nurse assesses the client's operative eye after surgery, which finding is most expected?
- A. The pupil appears cloudy and gray.
- B. The pupil is a fixed size and shape.
- C. The entire iris lacks color.
- D. A section of the iris appears black.
Correct Answer: B
Rationale: An iridectomy creates a fixed pupil opening to relieve pressure.
Which statement made to the nurse is the best evidence that the client understands the anticipated outcome of this procedure?
- A. I'm better night vision.
- B. I'll correctly identify colors.
- C. I'll see well without glasses.
- D. I'll use both eyes when reading.
Correct Answer: C
Rationale: LASIK corrects refractive errors, reducing the need for glasses.
The nurse is admitting an 88-year-old client diagnosed with a viral skin infection. Which nursing task could the nurse delegate to the unlicensed assistive personnel?
- A. Measure and document the client’s skin lesions.
- B. Apply the antihistamine cream to the lesions.
- C. Set up the isolation equipment for the client.
- D. Determine if the client has prepared an advance directive.
Correct Answer: C
Rationale: Setting up isolation equipment is within UAP scope. Measuring lesions, applying medication, and assessing advance directives require nursing judgment.