Nokea
When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?
- A. Assessing the client's bowel sounds
- B. administration of pain medication every 4 hours
- C. Evaluating the client's response to antidiarrheal medications
- D. Maintaining intake and output records
Correct Answer: D
Rationale: Delegating tasks such as providing skin care, maintaining intake and output records, and obtaining the client's weight are within the scope of practice for an unlicensed assistant. Assessing bowel sounds and evaluating the response to medications require nursing judgment and should not be delegated.
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Stephen is a 62 y.o. patient that has had a liver biopsy. Which of the following groups of signs alert you to a possible pneumothorax?
- A. Dyspnea and reduced or absent breath sounds over the right lung
- B. Tachycardia, hypotension, and cool, clammy skin
- C. Fever, rebound tenderness, and abdominal rigidity
- D. Redness, warmth, and drainage at the biopsy site
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Arthur has a family history of colon cancer and is scheduled to have a sigmoidoscopy. He is crying as he tells you, "I know that I have colon cancer, too." Which response is most therapeutic?
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Correct Answer: B
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You're caring for a 28 y.o. woman with hepatitis B. She's concerned about the duration of her recovery. Which response isn't appropriate?
- A. Encourage her to not worry about the future.
- B. Encourage her to express her feelings about the illness.
- C. Discuss the effects of hepatitis B on future health problems.
- D. Provide avenues for financial counseling if she expresses the need.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
You have to teach ostomy self care to a patient with a colostomy. You tell the patient to measure and cut the wafer:
- A. To the exact size of the stoma.
- B. About 1/16" larger than the stoma.
- C. About 1/8" larger than the stoma.
- D. About 1/4″ larger than the stoma.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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- A. Aspirate for gastric secretions with a syringe.
- B. Begin feeding slowly to prevent cramping.
- C. Get an X-ray of the tip of the tube within 24 hours.
- D. Clamp off the tube until the feedings begin.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.