Nokea
Which of the following tasks can the practical nurse (PN) safely assign to an experienced unlicensed assistive personnel (UAP)? Select all that apply.
- A. Ambulate an oxygen-dependent client to the bathroom
- B. Check pulse oximetry for a client with respiratory rate 12/min
- C. Instruct a client with pneumonia on usage of the incentive spirometer
- D. Provide oral hygiene to a client with chronic obstructive pulmonary disease (COPD)
- E. Turn and reposition a client with pneumonia
Correct Answer: A,B,D,E
Rationale: UAP can ambulate stable clients , check pulse oximetry , provide oral hygiene , and reposition clients . Instructing on incentive spirometry requires nursing judgment and is not delegable.
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The nurse is reinforcing information to a diabetic client with a new prescription for metoclopramide. Which of the following side effects must the nurse remind the client to report immediately to the health care provider? Select all that apply.
- A. Excess blinking of eyes
- B. Dry mouth
- C. Dull headache
- D. Lip smacking
- E. Puffing of cheeks
Correct Answer: A,D,E
Rationale: Metoclopramide can cause tardive dyskinesia, with symptoms like excess blinking , lip smacking , and cheek puffing , requiring immediate reporting. Dry mouth and headache are common and less urgent.
A client is scheduled for a myelogram. Which of the following medications orders should be questioned?
- A. Ampicillin (Pencipen) $250 \mathrm{mg} \mathrm{PO} \mathrm{q} 6$ hours
- B. Motrin (Ibuprofen) $400 \mathrm{mg} \mathrm{PO} \mathrm{q} 4$ hours PRN for headache
- C. Secobarbital (Seconal) $50 \mathrm{mg}$ HS PRN for sleep
- D. Propoxyphene (Darvon) $65 \mathrm{mg} \mathrm{PO} \mathrm{q} 4$ hours for pain
Correct Answer: B
Rationale: Ibuprofen (Motrin) has anticoagulant properties, increasing bleeding risk during a myelogram, a procedure involving spinal puncture. Other medications are safer.
An adult woman who has multiple sclerosis (MS) asks the nurse why she developed multiple sclerosis. What information should the nurse include when responding?
- A. MS usually follows a streptococcal infection.
- B. MS is an autoimmune condition.
- C. MS occurs more often among persons who have had chickenpox.
- D. MS may be related to mosquito bites.
Correct Answer: B
Rationale: Multiple sclerosis is an autoimmune disorder where the immune system attacks myelin in the central nervous system, unlike infections or mosquito bites.
The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
- A. Apply dressing using sterile technique
- B. Improve the client's nutrition status
- C. Initiate limb elevation and compression
- D. Begin proteolytic debridement
Correct Answer: B
Rationale: The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other interventions are appropriate, but without proper nutrition, they would be of little help.
Vital signs
Temperature 100.9 F (38.3 C)
Blood pressure 125/75 mm Hg
Heart rate 109/min
Respirations 15/min
SpO2 100%
The nurse is caring for a postpartum client 36 hours after a cesarean birth who was just diagnosed with postpartum endometritis. Which prescription is priority for the nurse to administer?
- A. Acetaminophen PO PRN for fever
- B. Clindamycin IV every 8 hours
- C. Lactated Ringer IV bolus once
- D. Methylergonovine PO every 4 hours
Correct Answer: B
Rationale: Postpartum endometritis requires prompt antibiotic treatment, so clindamycin IV is the priority to address the infection. Acetaminophen , fluids , and methylergonovine are supportive or unrelated.