Which of the following organs is most likely to suffer permanent damage from shock?
- A. The heart
- B. The skin
- C. The brain
- D. The kidneys
Correct Answer: D
Rationale: The kidneys are highly susceptible to permanent damage from shock due to reduced perfusion, leading to acute kidney injury.
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The charge nurse in a long-term memory care facility is making assignments for the Alzheimer unit. Which tasks may be delegated to experienced unlicensed assistive personnel? Select all that apply.
- A. Assisting clients with bathing and hair care
- B. Evaluating safety hazards in clients' rooms
- C. Monitoring clients for behavioral changes
- D. Placing bed alarms at night for clients at risk for wandering
- E. Reporting a client's swallowing difficulties during mealtime
Correct Answer: A,D,E
Rationale: Bathing/hair care (A), placing bed alarms (D), and reporting swallowing issues (E) are within UAP scope. Evaluating hazards (B) and monitoring behavior changes (C) require nursing judgment.
The nursing assistant is caring for an adult who has a fractured femur and is in Buck's extension traction awaiting surgery. The nurse is observing the nursing assistant administer morning care. Which action by the nursing assistant needs correction?
- A. The nursing assistant leaves the weights in place while bathing the client.
- B. The nursing assistant turns the client's head to the side while administering oral hygiene.
- C. The nursing assistant makes the bed from head to foot.
- D. The nursing assistant turns the client on the side for back care.
Correct Answer: D
Rationale: Turning the client on the side disrupts Buck's traction alignment, which requires constant pull. Weights should stay in place, head turning is safe, and bed-making direction is irrelevant.
The nurse is caring for a client with bulimia nervosa. It would be a priority for the nurse to
- A. place limits on the time allowed for client meals
- B. check on the client at irregular intervals during the overnight hours
- C. monitor the client for 1 to 2 hours after each meal
- D. discuss complications associated with bulimia nervosa with the client
Correct Answer: C
Rationale: Monitoring for 1-2 hours after meals (C) prevents purging, a priority in bulimia management. Time limits (A) may increase anxiety, overnight checks (B) are less relevant, and discussing complications (D) is educational but not immediate.
The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find?
- A. Complaints of numbness and tingling in feet
- B. Wheezing noted when lung sounds auscultated
- C. Excessive perspiration
- D. Difficulty sleeping
Correct Answer: A
Rationale: Complaints of numbness and tingling in feet. A child who has unusual neurologic signs or symptoms, neuropathy, footdrop, or anemia that cannot be attributed to other causes may be suffering from lead poisoning. This most often occurs when a child ingests or inhales paint chips from lead-based paint or dust from remodeling in older buildings.
Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:
- A. Offer the baby sterile water between feedings of formula
- B. Apply an emollient to the baby's skin to prevent drying
- C. Wear a gown, gloves, and a mask while caring for the infant
- D. Place the baby on enteric isolation
Correct Answer: B
Rationale: Applying an emollient prevents skin drying, a common issue during phototherapy due to exposure to light.
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