Nokea
Which of the following is true with regard to delegation of client care responsibilities? Select all that apply.
- A. The nurse must know the nursing model that underlies care at the institution.
- B. The nurse delegates in accordance with demands on his/her time.
- C. The nurse validates with the non-RN caregiver that he/she has performed the same activity before.
- D. The nurse retains the right to determine which tasks are delegated.
- E. The nurse must account that the task has been delegated and to whom.
Correct Answer: A, C, D, E
Rationale: Delegation involves understanding the care model, validating caregiver competency, determining tasks, and documenting delegation, but not delegating based solely on time demands.
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Select the step of blood glucose level monitoring that is NOT accurate.
- A. Turn the finger down so the blood will drop with gravity.
- B. Wipe off the first drop of blood using sterile gauze.
- C. Prick the side of the finger using the lancet.
- D. Prick the pad of the finger using the lancet.
Correct Answer: D
Rationale: Pricking the pad of the finger is less accurate and more painful; the side of the finger is the preferred site for blood glucose monitoring.
An infusion of lidocaine hydrochloride (Xylocaine) is running at 30 mL/hour. The dilution is 1,000 mg/250 mL. What dosage is the client receiving per minute?
Correct Answer: 2 mg/minute.
Rationale: Calculate: 1,000 mg in 250 mL = 4 mg/mL. At 30 mL/hour, that's 30 mL × 4 mg/mL = 120 mg/hour. Per minute: 120 mg ÷ 60 min = 2 mg/minute.
A client is receiving a continuous infusion of heparin. The nurse notes a partial thromboplastin time (PTT) of 120 seconds. What should the nurse do first?
- A. Stop the infusion
- B. Reduce the infusion rate
- C. Administer protamine sulfate
- D. Notify the physician
Correct Answer: A
Rationale: A PTT of 120 seconds is significantly above the therapeutic range (1.5 to 2 times normal), indicating a risk of bleeding. Stopping the infusion is the first action to prevent harm.
Which of the following measures should be implemented promptly after a client's nasogastric (NG) tube has been removed?
- A. Provide the client with oral hygiene.
- B. Offer the client liquids to drink.
- C. Encourage the client to cough and deep breathe.
- D. Auscultate the client's bowel sounds.
Correct Answer: A
Rationale: Oral hygiene removes residual tube-related irritation and promotes comfort after NG tube removal.
A client has been prescribed metoprolol for hypertension. The nurse monitors client compliance carefully because of which common side effect of the medication?
- A. Impotence
- B. Mood swings
- C. Increased appetite
- D. Complete atrioventricular (AV) block
Correct Answer: A
Rationale: A common side effect of beta-adrenergic blocking agents, such as metoprolol, is impotence. Other common side effects include fatigue and weakness. Central nervous system side effects occur rarely and include mental status changes, nervousness, depression, and insomnia. Mood swings, increased appetite, and complete AV block are not reported side effects.