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Which action by the unlicensed assistive personnel (UAP) would warrant immediate intervention by the nurse?
- A. The UAP is holding the phone to the ear of a client who is a quadriplegic.
- B. The UAP refuses to discuss the client's condition with the visitor in the room.
- C. The UAP put a vest restraint on an elderly client found wandering in the hall.
- D. The UAP is assisting the client with arthritis to open up personal mail.
Correct Answer: C
Rationale: Applying restraints without a physician’s order violates safety and legal standards, requiring intervention. Other actions are appropriate UAP tasks.
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The nurse is caring for the family of the client who has just died. Which is the nurse's priority action?
- A. Be with the family.
- B. Call the funeral home.
- C. Notify the minister.
- D. Fill out the death certificate.
Correct Answer: A
Rationale: Being with the family provides immediate emotional support, a nursing priority post-death. Funeral, minister, or certificate tasks are secondary.
Which document is the best professional source to provide direction for a nurse when addressing ethical issues and behavior?
- A. The Hippocratic Oath.
- B. The Nuremberg Code.
- C. Home Health Care Bill of Rights.
- D. ANA Code of Ethics.
Correct Answer: D
Rationale: The ANA Code of Ethics guides nurses on ethical behavior and decision-making, specific to nursing practice. Other documents are less relevant or outdated.
The client tells the nurse, 'Every time I come in the hospital you hand me one of these advance directives (AD). Why should I fill one of these out?' Which statement by the nurse is most appropriate?
- A. You must fill out this form because Medicare laws require it.
- B. An AD lets you participate in decisions about your health care.
- C. This paper will ensure no one can override your decisions.
- D. It is part of the hospital admission packet and I have to give it to you.
Correct Answer: B
Rationale: Advance directives allow clients to specify their health care preferences, ensuring participation in decisions, per the Patient Self-Determination Act. Medicare requires offering, not completing, ADs; no document guarantees non-override; and packet inclusion is procedural, not the reason.
The client diagnosed with chronic back pain is being placed on a transcutaneous electrical nerve stimulation (TENS) unit. Which information should the nurse teach?
- A. The TENS unit will deaden the nerve endings, and the client will not feel pain.
- B. The TENS unit could cause paralysis if the client gets the unit wet.
- C. The TENS unit stimulates the nerves in the area, blocking the pain sensation.
- D. The TENS unit should be left on for an hour, and then taken off for an hour.
Correct Answer: C
Rationale: TENS units stimulate nerves to block pain signals, per gate control theory. Deadening nerves, paralysis, or specific on/off cycles are inaccurate.
The nurse is assessing a client diagnosed with chronic pain. Which characteristics would the nurse observe?
- A. The client's blood pressure is elevated.
- B. The client has rapid shallow respirations.
- C. The client has facial grimacing.
- D. The client is lying quietly in bed.
Correct Answer: C
Rationale: Chronic pain may not cause vital sign changes but often manifests as facial grimacing, per pain assessment guidelines. Lying quietly can occur but isn’t diagnostic.