Nokea
When walking past a client's room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention?
- A. If we work together we can get all of the client care completed.
- B. Since I am late for lunch, would you do this one client's glucose test?
- C. If we client seems confused, we need to watch another closely.
- D. I'll come back and make the bed after I go to the lab.
Correct Answer: B
Rationale: Only the RN and PN can delegate to UAPs. One UAP cannot delegate a task to another UAP. The RN or PN is legally accountable for the nursing care.
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While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age?
- A. 1 year of age
- B. 2 years of age
- C. 3 years of age
- D. 4 years of age
Correct Answer: B
Rationale: 2 years of age. A child should be at least 2 years of age to use the radial pulse to assess heart rate.
The nurse is assessing a 1-month-old infant with atrial septal defect. Which of the following findings would be consistent with the condition?
- A. cyanosis
- B. muffled heart tones
- C. murmur
- D. weak femoral pulses
Correct Answer: C
Rationale: An atrial septal defect often presents with a heart murmur due to abnormal blood flow. Cyanosis is rare unless severe, muffled tones are not typical, and weak femoral pulses suggest coarctation of the aorta.
After passing a nasogastric (NG) tube in an adult, the nurse checks for proper placement by doing which of the following?
- A. Injecting air into the NG tube and listening with a stethoscope over the stomach for a 'swoosh'
- B. Putting the end of the NG tube in a glass of water and observing for bubbles
- C. Asking the client if the tube is comfortable
- D. Aspirating contents and checking the pH
Correct Answer: D
Rationale: Aspirating gastric contents and checking pH (typically 1-5 for stomach) is the most reliable method to confirm NG tube placement in the stomach. Air injection is less definitive, water bubbling is unsafe, and comfort does not confirm placement.
When counseling a 6 year-old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder?
- A. It has no clear etiology
- B. Enuresis may be associated with sleep phobia
- C. It has a definite genetic link
- D. Enuresis is a sign of willful misbehavior
Correct Answer: A
Rationale: It has no clear etiology. Enuresis has multiple contributing factors, but no single definitive cause has been established.
A client with Parkinson's disease complains of 'choking' when he swallows. Which intervention will improve the client's ability to swallow?
- A. Withholding liquids until after meals
- B. Providing semi-liquids when possible
- C. Providing a full liquid diet
- D. Offering small, more frequent meals
Correct Answer: B
Rationale: Semi-liquids are easier to swallow for Parkinson's patients with dysphagia. Withholding liquids risks dehydration. Full liquid diets may be too thin. Small meals help nutrition but not swallowing.