Nokea
Which client should the nurse safely assign to the unlicensed assistive personnel (UAP)?
- A. A client requiring dressing changes
- B. A client requiring frequent ambulation
- C. A client on a bowel management program requiring rectal suppositories
- D. A client newly admitted with nausea, vomiting, and moderate neck pain
Correct Answer: B
Rationale: Assignment of tasks to UAP needs to be made based on job description, level of clinical competence, and state law. The client described in option 2 has needs, frequent ambulation, that can be met by UAP. Options 1, 3, and 4 involve care that requires the skill of a licensed nurse.
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The nurse manager is observing the interaction between a new staff nurse and a client currently receiving hemodialysis. Which intervention should the nurse manager implement when the nurse and client are both drinking coffee and discussing the client's feeling about the procedure?
- A. Getting a cup of coffee and join in on the conversation
- B. Determining whether or not the client should be drinking coffee
- C. Complementing the staff nurse on the development of a good therapeutic relation
- D. Asking the staff nurse to refrain from eating and drinking in the hemodialysis area
Correct Answer: D
Rationale: The nurse manager should ask the second nurse to stop eating and drinking in the client area. A potential complication of hemodialysis is the acquisition of dialysis-associated hepatitis B. This is a concern for clients (who may carry the virus), client families (at risk from contact with the client and with environmental surfaces), and staff (who may acquire the virus from contact with the client's blood). This risk is minimized by the use of standard precautions; appropriate hand-washing and sterilization procedures; and the prohibition of eating, drinking, or other hand-to-mouth activity in the hemodialysis unit. None of the remaining options relate to management of this potential complication.
A friend of the parents of a newborn with a diagnosis of congenital tracheoesophageal fistula contacts the home health nurse with an offer to help. Which is the best nursing action at this time to address the needs and rights of the family?
- A. Inform the friend to directly contact the family and offer assistance to them.
- B. Request that the friend come to the client's home during the next home health visit.
- C. Report the friend's call to the nurse manager for referral to the client's social worker.
- D. Assure the friend that there is no need for assistance since the nurse is visiting daily.
Correct Answer: A
Rationale: The nurse must uphold the client's rights and does not give any information regarding a client's care needs to anyone who is not directly involved in the client's care. To request that the friend come for teaching is a direct violation of the client's right to privacy. There is no information in the question to indicate that the family desires assistance from the friend. To refer the call to the nurse manager and social worker again assumes that the friend's assistance and involvement are desired by the family. Informing the friend that the nurse is visiting daily is providing information that is considered confidential. Option 1 directly refers the friend to the family.
A client has a prescription for valproic acid 250 mg once daily. To maximize the client's safety, which time is best for the nurse to schedule administration of the medication?
- A. With lunch
- B. With breakfast
- C. Before breakfast
- D. At bedtime with a snack
Correct Answer: D
Rationale: Valproic acid is an anticonvulsant that causes central nervous system (CNS) depression. For this reason, the side and adverse effects include sedation, dizziness, ataxia, and confusion. When the client is taking this medication as a single daily dose, administering it at bedtime negates the risk of injury from sedation and enhances client safety. Otherwise, it may be given after meals to avoid gastrointestinal upset.
The nurse is preparing the client's morning prescribed NPH insulin dose and notices a clumpy precipitate inside the insulin vial. Which action should the nurse implement?
- A. Draw the dose from a new vial.
- B. Draw up and administer the dose.
- C. Shake the vial in an attempt to disperse the clumps.
- D. Warm the bottle under running water to dissolve the clump.
Correct Answer: A
Rationale: The nurse should always inspect the vial of insulin before use for solution changes that may signify loss of potency. NPH insulin is normally uniformly cloudy. Clumping, frosting, and precipitates are signs of insulin damage. In this situation, because potency is questionable, it is safer to discard the vial and draw up the dose from a new vial.
The nurse, after administering an injection to a client, accidentally drops the syringe on the floor. Which nursing action is most appropriate in this situation?
- A. Obtain a dust pan and mop to sweep up the syringe.
- B. Call the housekeeping department to pick up the syringe.
- C. Carefully pick up the syringe from the floor and gently recap the needle.
- D. Carefully pick up the syringe from the floor and dispose of it in a sharps container.
Correct Answer: D
Rationale: Used syringes should always be placed in a sharps container immediately after use to avoid individuals from becoming injured. A syringe should not be swept up because this action poses an additional risk for getting pricked. It is not the responsibility of the housekeeping department to pick up the syringe. Syringes should never be recapped under any circumstances because of the risk of getting pricked with a contaminated needle.