Which action should you delegate to the nursing assistant for the client with diabetic ketoacidosis? (Choose all that apply.)
- A. Check fingerstick glucose every hour
- B. Record intake and output every hour
- C. Check vital signs every 15 minutes
- D. Assess for indicators of fluid imbalance
Correct Answer: A
Rationale: Checking fingerstick glucose and recording intake/output are routine tasks that can be delegated to a nursing assistant. Assessing fluid imbalance and checking vital signs frequently require more skilled nursing judgment.
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The World Health Organization (WHO) recommends the use of three-step analgesic ladder when deciding on pain management. In order of first choice to second choice to third choice, the following drug categories are used:
- A. NSAIDs,nonopioids and opioids
- B. Nonopioids opioid antagonists and opioids
- C. Nonopioids opioids and adjuvant agents
- D. NSAIDs opioids and adjuvant agent
Correct Answer: C
Rationale: The WHO analgesic ladder starts with nonopioid analgesics (e.g., acetaminophen), progresses to weak opioids if needed, and finally includes strong opioids along with adjuvant therapies for severe pain.
Why does the nurse advise a client with painless lesions, after exposure to anthrax, to avoid contact with others?
- A. So the client is not exposed to pathogens.
- B. Because the sight of the lesions may cause distress and panic.
- C. Because the lesions may release more spores.
- D. Skin infection is one form of anthrax that spreads by direct contact.
Correct Answer: C
Rationale: The correct answer is C because anthrax lesions can release spores that may infect others.
Why does the circulating nurse remove a tightly rolled blanket from under Mrs. West’s knees?
- A. Prevent damage to nerves and circulation
- B. Provide a flat surface for the sterile field
- C. Stretch lower leg muscles to prevent strain
- D. Facilitate access to the surgical site
Correct Answer: A
Rationale: Improper positioning can cause nerve compression and circulatory issues.
A preoperative patient reveals that an uncle died during surgery because of a fever and cardiac arrest. Knowing the patient is at risk for malignant hyperthermia, the perioperative nurse alerts the surgical team. What is likely to happen next?
- A. The surgery will have to be cancelled.
- B. Specific precautions can be taken to safely anesthetize the patient.
- C. Dantrolene (Dantrium) must be given to prevent hyperthermia during surgery.
- D. The patient should be placed on a cooling blanket during the surgical procedure.
Correct Answer: B
Rationale: With awareness of malignant hyperthermia risk, specific precautions ensure safe anesthesia administration.
In which direction does the nurse hold the syringe when irrigating the ear to remove wax?
- A. Toward the roof of the canal
- B. Toward the eardrum
- C. Toward the nasal cavity
- D. Toward the helix
Correct Answer: A
Rationale: Directing the stream toward the roof of the canal helps dislodge wax without damaging the eardrum.