Nokea
Which of the following tasks are appropriate for the nurse to delegate to unlicensed assistive personnel? Select all that apply.
- A. Checking temperature and vital signs for a client acutely ill with sepsis.
- B. Checking routine temperature and vital signs for clients at the beginning of the shift.
- C. Emptying catheter bags and measuring the urinary output from Foley catheters.
- D. Monitoring the transfusion of red blood cells.
- E. Assisting an ambulatory client to walk to the bathroom.
Correct Answer: B,C,E
Rationale: Unlicensed assistive personnel can perform routine tasks like checking routine vital signs (B), measuring urinary output (C), and assisting with ambulation (E). Checking vital signs in an acutely ill client (A) and monitoring a transfusion (D) require a nurse's assessment skills.
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The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
- A. BP 146/88
- B. Respirations 28 shallow
- C. Weight gain of 10 pounds in 6 months
- D. Pink complexion
Correct Answer: B
Rationale: Tachypnea (respirations 28 shallow) is a common sign of anemia due to reduced oxygen-carrying capacity, prompting compensatory increased respiratory rate.
The nurse is caring for a client with an endemic goiter. The nurse recognizes that the client's condition is related to:
- A. Living in an area where the soil is depleted of iodine
- B. Eating foods that decrease the thyroxine level
- C. Using aluminum cookware to prepare the family's meals
- D. Taking medications that decrease the thyroxine level
Correct Answer: A
Rationale: Endemic goiter is caused by iodine deficiency, often due to low iodine levels in soil, leading to inadequate thyroid hormone production.
The doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows antithrombolic stockings should be applied:
- A. Before rising in the morning
- B. With the client in a standing position
- C. After bathing and applying powder
- D. Before retiring in the evening
Correct Answer: A
Rationale: Applying antithrombic stockings before rising prevents venous pooling, maximizing their effectiveness in improving circulation.
A 60-year-old diabetic is taking glyburide (Diabeta) 1.25 mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching?
- A. I will keep candy with me just in case my blood sugar drops.
- B. I need to stay out of the sun as much as possible.
- C. I often skip dinner because I don't feel hungry.
- D. I always wear my medical identification.
Correct Answer: C
Rationale: Skipping meals while on glyburide increases hypoglycemia risk, indicating a need for further teaching.
The nurse is caring for a client who is receiving mechanical ventilation. The ventilator alarms are sounding, and the nurse notes high-pressure alarms. Which of the following actions should the nurse take FIRST?
- A. Suction the client’s airway.
- B. Notify the respiratory therapist.
- C. Check the ventilator tubing for kinks.
- D. Administer a bronchodilator.
Correct Answer: C
Rationale: checking for kinks in the tubing is the first step, as it is a common cause of high-pressure alarms