Nokea
Which activity is appropriate to assign to a certified nursing assistant?
- A. Evaluate vital signs.
- B. Monitor tube feedings.
- C. Assist with activities of daily living (ADLs).
- D. Discuss discharge instructions.
Correct Answer: C
Rationale: Assisting with ADLs is within a CNA's scope, unlike evaluating vitals, monitoring feedings, or discussing instructions, which require nursing judgment.
You may also like to solve these questions
Intake and output record
Time Oral intake Parenteral intake Other intake Output
0700 150 mL vancomycin IV
0900 240 mL coffee 1500 mL dialysate
1100 120 mL tea
1300 100 mL cefepime IV 1400 mL dialysate outflow
1500 180 mL juice
The nurse is completing a client's intake and output record for the shift. How many mL should the nurse record as the client's net fluid balance for the shift?
Correct Answer: 890
Rationale: Without specific intake/output data, a general approach is assumed: net fluid balance is calculated as total intake (IV, oral, etc.) minus total output (urine, emesis, etc.). For example, if intake is 2000 mL and output is 1800 mL, the balance is 200 mL. The nurse must sum all recorded values accurately.
A client is receiving lithium carbonate 600 mg T.I.D. to treat bipolar disorder. Which of these indicate early signs of toxicity?
- A. Ataxia and coarse hand tremors
- B. Vomiting, diarrhea and lethargy
- C. Pruritus, rash and photosensitivity
- D. Electrolyte imbalance and cardiac arrhythmias
Correct Answer: B
Rationale: Vomiting, diarrhea, and lethargy are early signs of lithium toxicity.
A client with allergic rhinitis has an order for a long-acting nasal spray that contains oxymetazoline. The client should be instructed to use the spray as directed to prevent:
- A. Bleeding tendencies
- B. Increased nasal congestion
- C. Nasal polyps
- D. Tinnitus
Correct Answer: B
Rationale: Overuse of oxymetazoline can cause rebound nasal congestion (rhinitis medicamentosa). It does not typically cause bleeding, nasal polyps, or tinnitus.
An adult is admitted with a head injury following an accident. He has a severe headache and asks the nurse why he cannot have something for pain. The nurse understands that the client should not receive a narcotic analgesic for which reason?
- A. Narcotic analgesics cause mydriasis, which will raise intracranial pressure.
- B. Narcotic analgesics are not effective for pain caused by brain trauma.
- C. Narcotic analgesics cause vomiting, which would mask a sign of increased intracranial pressure.
- D. Narcotic analgesics may depress respirations, which would cause acidosis and further brain damage.
Correct Answer: D
Rationale: Narcotics depress respirations, risking CO2 retention, acidosis, and increased intracranial pressure in head injury clients. Mydriasis, ineffectiveness, or vomiting are less critical concerns.
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
- A. Replenish her supply every three months.
- B. Take one every 15 minutes if pain occurs.
- C. Leave the medication in the brown bottle.
- D. Crush the medication and take it with water.
Correct Answer: C
Rationale: The client should leave the medication in the brown bottle because light deteriorates the medication. The supply should be replenished every six months, so answer A is incorrect. One tablet should be taken every five minutes times three, so answer B is incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, so answer D is incorrect.