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Which client should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. A client who needs teaching regarding the use of an incentive spirometer
- B. A client who needs to have a urine specimen collected for a clean catch urine
- C. A client who needs reinforcement of a dressing covering an abdominal incision
- D. A client who needs assessment of a newly identified area of pressure over the right hip
Correct Answer: B
Rationale: The UAP can assist with specimen collection such as a clean catch urine because he or she is trained in this skill. Skills requiring nursing intervention such as dressing changes, teaching, and assessment cannot be delegated to unlicensed personnel.
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The nurse is administering epoetin alfa to a client diagnosed with chronic kidney disease (CKD). For which adverse effect of this therapy should the nurse monitor the client?
- A. Anemia
- B. Hypertension
- C. Iron intoxication
- D. Bleeding tendencies
Correct Answer: B
Rationale: The client taking epoetin alfa is at risk of hypertension and seizure activity as the most serious adverse effects of therapy. This medication is used to treat anemia. The medication does not cause iron intoxication. Bleeding tendencies is not an adverse effect of this medication.
A primiparous client at 38 weeks' gestation is admitted in early labor. The client's membranes rupture, and the nurse observes that the amniotic fluid is meconium-stained. The nurse should:
- A. Notify the physician immediately.
- B. Perform a vaginal exam to assess dilation.
- C. Encourage the client to ambulate.
- D. Administer oxygen to the client.
Correct Answer: A
Rationale: Meconium-stained amniotic fluid may indicate fetal distress, requiring immediate notification of the physician for further evaluation and management.
A nurse has been working with a battered woman who is being discharged and returning home with her husband. The nurse says, 'All this work with her has been useless. She's just going back to him as usual.' Which of the following statements by a nursing colleague would be most helpful to this nurse?
- A. Her reasons for staying are complex. She can leave only when she is ready and can be safe.'
- B. I know it is frustrating to work with clients who don't follow our advice.'
- C. I need to do you have her again and have another chance.'
- D. These women almost never leave for good because of their emotional and financial dependency.'
Correct Answer: A
Rationale: The colleague needs to provide the nurse with information about spouse abuse. Giving information about reasons for staying is useful for decreasing the nurse's frustration. Although expressing empathy is appropriate, it does not help the nurse understand the client's needs and behaviors. Telling the nurse that there will be another chance is not helpful and fails to educate the other nurse about the dynamics of abuse. Although dependence is a problem, women who are abused can overcome this and leave if they have support, not criticism.
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed fluticasone (Flovent). The nurse should instruct the client to:
- A. Rinse the mouth after inhalation.
- B. Use the inhaler as needed for shortness of breath.
- C. Take the inhaler with meals.
- D. Stop the inhaler if dizziness occurs.
Correct Answer: A
Rationale: Rinsing the mouth after fluticasone inhalation prevents oral thrush.
Which question is asked more than any other root cause analysis activity?
- A. What?
- B. Why?
- C. Who?
- D. When?
Correct Answer: B
Rationale: The 'Why?' question is central to root cause analysis, as it drives the investigation into the underlying causes of an event through techniques like the '5 Whys.'