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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The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?
- A. Cough and deep breathe every 2 hours.
- B. Place the client in contact isolation.
- C. Provide a diet high in protein.
- D. Institute seizure precautions.
Correct Answer: A
Rationale: Encouraging coughing and deep breathing helps prevent pulmonary complications.
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.
Treatment of the patient with appendicitis includes
- A. Transfusion to replace blood loss.
- B. Bowel preparation for cleansing.
- C. Surgical removal of appendix.
- D. Medications to lower pH within stomach.
Correct Answer: C
Rationale: Surgical removal of the appendix is the definitive treatment for appendicitis.
Until Mr. Jones’ diagnosis is confirmed, what should be a priority?
- A. Encouraging rest
- B. Monitoring intake and output
- C. Preventing spread of infection to others
- D. Providing attractive meals
Correct Answer: C
Rationale: The correct answer is C: Preventing spread of infection to others. This is the priority because until Mr. Jones' diagnosis is confirmed, it is crucial to prevent potential transmission of any infectious diseases to others. Encouraging rest (choice A) and providing attractive meals (choice D) are important for overall well-being but not as critical as preventing the spread of infection. Monitoring intake and output (choice B) is important for assessing Mr. Jones' health status but does not directly address the potential risk of infecting others. Therefore, choice C is the most immediate priority to ensure the safety of others.
A client in a clinic presents with an acute asthma exacerbation. Which of the following medications should reduce the symptoms?
- A. Cromolyn via a metered-dose inhaler
- B. Montelukast orally
- C. Budesonide via a dry-powder inhaler
- D. Albuterol via a jet nebulizer
Correct Answer: D
Rationale: The correct answer is D: Albuterol via a jet nebulizer. Albuterol is a short-acting beta agonist that works by relaxing the muscles in the airways, helping to open them up and improve airflow. When administered via a nebulizer, it provides quick relief during an acute asthma exacerbation by directly targeting the airways. Cromolyn (A) is a mast cell stabilizer that is used for preventing asthma symptoms, not for acute exacerbations. Montelukast (B) is a leukotriene receptor antagonist that is used for maintenance therapy, not for immediate relief. Budesonide (C) is an inhaled corticosteroid used for long-term control of asthma, not for acute symptom relief.