Nokea
Which nursing interventions should not be delegated to unlicensed assistive personnel (UAP) but should be performed by the RN (select all that apply)?
- A. Administering patient medications
- B. Ambulating stable patients
- C. Performing patient assessment
- D. Evaluating the effectiveness of patient care
Correct Answer: A
Rationale: Medication administration, assessment, evaluation, and teaching require the RN's specialized knowledge and accountability.
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Which measures or drugs may be effective in controlling pain in the physiologic pain process stage of transduction (select all that apply)?
- A. Distraction
- B. Corticosteroids
- C. Epidural opioids
- D. Local anesthetics
Correct Answer: D
Rationale: The correct answers are D, Local anesthetics, distraction, and NSAIDs target the transduction stage.
A client has undergone the Snellen eye chart and has 20/40 vision. Which of the following is true for this client?
- A. The client sees letters at 20 feet that others can read at 40 feet
- B. The client sees letters at 40 feet that others can read at 20 feet
- C. The client sees colors at 20 feet that others can see at 40 feet
- D. The client sees colors at 40 feet that others can see at 20 feet
Correct Answer: A
Rationale: 20/40 vision means the client can see at 20 feet what a person with normal vision can see at 40 feet.
To prepare a patient on the unit for a bronchoscopic procedure, the medical-surgical nurse administers an IV sedative. The nurse then instructs the licensed practical nurse to
- A. educate the patient about the procedure.
- B. give the patient small sips of water only.
- C. measure the patient's blood pressure and heart rate.
- D. take the patient to the bathroom one more time.
Correct Answer: D
Rationale: Emptying the bladder before the procedure is important for comfort and safety.
What is your evaluation of Mr. Smith’s skin rash and slight fever after taking INH for 3 months?
- A. Is developing hepatitis
- B. Has not been taking INH
- C. Is having a normal response to the medication
- D. Is demonstrating early signs of drug hypersensitivity
Correct Answer: D
Rationale: The correct answer is D because Mr. Smith's skin rash and slight fever after taking INH for 3 months indicate early signs of drug hypersensitivity. This is supported by the timing of symptoms appearing after prolonged use, which is typical for drug hypersensitivity reactions. Other choices are incorrect: A, developing hepatitis would show different symptoms; B, not taking INH would not explain the symptoms; C, a normal response would not involve rash and fever.
For which nursing diagnoses or collaborative problems common in postoperative patients has ambulation been found to be an appropriate intervention (select all that apply)?
- A. Impaired skin integrity related to incision
- B. Impaired mobility related to decreased muscle strength
- C. Risk for aspiration related to decreased muscle strength
- D. Ineffective airway clearance related to decreased respiratory excursion
Correct Answer: D
Rationale: Ambulation addresses multiple postoperative issues, including mobility, respiratory function, constipation, and thromboembolism prevention.