Nokea
Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel?
- A. Teach Credé’s maneuver to the client needing to void.
- B. Administer the tube feeding to the client who is quadriplegic.
- C. Assist with bowel training by placing the client on the bedside commode.
- D. Observe the client demonstrating self-catheterization technique.
Correct Answer: C
Rationale: Assisting with bowel training by placing the client on a commode (C) is within the UAP’s scope, involving physical assistance. Teaching (A), administering tube feedings (B), and observing techniques (D) require nursing judgment and are not delegable.
You may also like to solve these questions
The nurse identifies the concept of intracranial regulation disturbance in a client diagnosed with Parkinson’s Disease. Which priority intervention should the nurse implement?
- A. Keep the bed low and call light in reach.
- B. Provide a regular diet of three (3) meals per day.
- C. Obtain an order for home health to see the client.
- D. Perform the Braden scale skin assessment.
Correct Answer: A
Rationale: Parkinson’s increases fall risk due to bradykinesia and rigidity. Keeping the bed low and call light in reach (A) prioritizes safety. Diet (B), home health (C), and skin assessment (D) are secondary.
The nurse is working with several clients in a substance abuse clinic. Client A tells the nurse that another client, Client B, has 'started using again.' Which action should the nurse implement?
- A. Tell Client A the nurse cannot discuss Client B with him.
- B. Find out how Client A got this information.
- C. Inform the HCP that Client B is using again.
- D. Get in touch with Client B and have the client come to the clinic.
Correct Answer: D
Rationale: Allegations of relapse require direct assessment. Contacting Client B (D) allows the nurse to evaluate the situation respectfully. Discussing Client B with Client A (A) or probing Client A (B) breaches confidentiality, and informing the HCP (C) is premature without verification.
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?
- A. An oral anticoagulant medication.
- B. A beta blocker medication.
- C. An anti-hyperuricemic medication.
- D. A thrombolytic medication.
Correct Answer: A
Rationale: A TIA in a client with atrial fibrillation is likely due to cardioembolic stroke risk. Oral anticoagulants (A), such as warfarin or direct oral anticoagulants, are prescribed to prevent clot formation. Beta blockers (B) control heart rate, anti-hyperuricemics (C) treat gout, and thrombolytics (D) are used acutely, not for discharge prevention.
The female client with an incomplete T6 spinal cord transection asks the nurse for sexual health advice and the possibility of ever conceiving. Which statements by the nurse will be helpful to the client? Select all that apply.
- A. “You need to continue to use contraceptives if you do not wish to have children.”
- B. “Unfortunately, your injury prevents you from being able to conceive children.”
- C. “Because feeling is affected, it is not likely that you will be able to deliver a baby.”
- D. “Sexual intercourse is generally prohibited because it can worsen your condition.”
- E. “You can engage in sexual intimacy, but you may not be able to feel an orgasm.”
Correct Answer: A,E
Rationale: Although the client has an incomplete T6 SCI, the woman is still capable of becoming pregnant. The client with an incomplete T6 SCI is able to get pregnant. Although the client may not feel the onset of labor, she may still be able to deliver the baby vaginally or via cesarean section. Sexual intercourse is allowable and would not worsen the client’s condition. The female may not be able to feel an orgasm. The client may not be able to feel an orgasm after an incomplete T6 SCI.
Which client statement indicates a need for further teaching about post-craniotomy care?
- A. I'll avoid coughing forcefully.'
- B. I'll sleep with my head elevated.'
- C. I can lift heavy objects after a week.'
- D. I'll report severe headaches immediately.'
Correct Answer: C
Rationale: Lifting heavy objects post-craniotomy can increase intracranial pressure; clients should avoid this for several weeks.