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Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Draw the serum liver function test.
- B. Evaluate the client’s intake and output.
- C. Perform the bedside glucometer check.
- D. Help the ward clerk transcribe orders.
Correct Answer: C
Rationale: Performing a glucometer check is within the UAP’s scope with proper training. Drawing blood, evaluating intake/output, and transcribing orders require RN skills.
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The nurse is completing the client’s hospital admission history. Which statement should prompt the nurse to further question the client about symptoms associated with GERD?
- A. “I have been experiencing headaches immediately after eating.”
- B. “Lately, I wake up at night with a burning feeling in my chest.”
- C. “I have been waking up at night sweating and wet all over.”
- D. “Immediately after eating I feel sleepy and want to go to bed.”
Correct Answer: B
Rationale: A. Headaches are a symptom not related to GERD. B. Heartburn, which is described as a burning, tight sensation in the lower sternum, is the most common symptom of GERD. It will often wake the client from sleep. C. Night sweats are a symptom not related to GERD. D. Postprandial sleepiness is a symptom not related to GERD.
The client who has had an appendectomy and has a Penrose drain in place has recovered from anesthesia. The nurse places her in a semi-sitting position. What is the primary reason for selecting this position?
- A. To promote optimal ventilation
- B. To promote drainage from the abdominal cavity
- C. To prevent pressure sores from developing
- D. To reduce tension on the suture line
Correct Answer: B
Rationale: The semi-sitting position promotes gravity-dependent drainage through the Penrose drain from the abdominal cavity.
When an elderly client is receiving cimetidine [Tagamet], it is important that the nurse monitor for which side effect?
- A. Chest pain
- B. Confusion
- C. Dyspnea
- D. Urinary retention
Correct Answer: B
Rationale: Confusion is a potential side effect of cimetidine in elderly clients due to its central nervous system effects.
The nurse is preparing to administer 250 mL of intravenous antibiotic to the client. The medication must infuse in one (1) hour. An intravenous pump is not available and the nurse must administer the medication via gravity with IV tubing at 10 gtts/min. At what rate should the nurse infuse the medication?
Correct Answer: 42 gtts/min
Rationale: Volume = 250 mL, time = 60 min, drop factor = 10 gtts/mL. Drip rate = (250 × 10) ÷ 60 = 41.67, rounded to 42 gtts/min.
The nurse has been assigned to care for four clients. Which client should the nurse plan to assess first?
- A. The 50-year-old client who has chronic pancreatitis and is reporting a pain level of 6 out of 10 on a numerical scale
- B. The 47-year-old client with esophageal varices who has influenza and has been coughing for the last 30 minutes
- C. The 60-year-old client who had an open cholecystectomy 15 hours ago and has been stable through the night
- D. The 54-year-old client with cirrhosis and jaundice who is reporting having itching all over the body
Correct Answer: B
Rationale: A. The client with a pain rating of 6 out of 10 on a numerical scale needs attention, but the pain is not a life-threatening concern. B. Bleeding esophageal varices are the most life-threatening complication of cirrhosis. Coughing can precipitate a bleeding episode. The nurse should assess this client first. C. The client who is postcholecystectomy is reported as being stable and could be assessed last. D. The client reporting itching needs attention, but the itching is not a life-threatening concern.