Nokea
Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Evaluate the client’s intake and output.
- B. Take the client’s vital signs.
- C. Change the client’s intravenous solution.
- D. Assess the client’s perianal area.
Correct Answer: B
Rationale: Taking vital signs is within the UAP’s scope and supports monitoring in gastroenteritis. Evaluating intake/output, changing IV solutions, and assessing skin require RN skills.
You may also like to solve these questions
The 84-year-old client comes to the clinic complaining of right lower abdominal pain. Which question is most appropriate for the nurse to ask the client?
- A. When was your last bowel movement?
- B. Did you have a high-fat meal last night?
- C. Can you describe the type of pain?
- D. Have you been experiencing any gas?
Correct Answer: C
Rationale: Describing the type of pain (e.g., sharp, dull, colicky) helps differentiate causes like appendicitis, diverticulitis, or obstruction, guiding diagnosis. Bowel movements, diet, and gas are secondary.
The nurse at the scene of a knife fight is caring for a young man who has a knife in his abdomen. Which action should the nurse implement?
- A. Stabilize the knife.
- B. Remove the knife gently.
- C. Turn the client on the side.
- D. Apply pressure to the insertion site.
Correct Answer: A
Rationale: Stabilizing the knife prevents further internal damage until surgical intervention. Removing it, turning the client, or applying pressure risks worsening bleeding.
Which assessment data supports the client's diagnosis of gastric ulcer to the nurse?
- A. Presence of blood in the client's stool for the past month.
- B. Reports of a burning sensation moving like a wave.
- C. Sharp pain in the upper abdomen after eating a heavy meal.
- D. Complaints of epigastric pain 30 to 60 minutes after ingesting food.
Correct Answer: D
Rationale: Gastric ulcers typically cause epigastric pain 30–60 minutes after eating due to acid irritation of the ulcerated mucosa. Blood in stool is more indicative of lower GI issues, a wave-like sensation is vague, and sharp pain after heavy meals is less specific.
A 32-year-old female is admitted for a hemorrhoidectomy. During the nursing assessment, all of the following factors are elicited. Which one is most likely to have contributed to the development of hemorrhoids?
- A. The client states that she usually cleans herself from back to front after a bowel movement.
- B. The client says her mother and grandmother had hemorrhoids.
- C. The client has had four pregnancies.
- D. The client eats bran every day.
Correct Answer: C
Rationale: Multiple pregnancies increase intra-abdominal pressure, a major risk factor for hemorrhoids. Family history may contribute, but pregnancies are more directly linked.
The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and T 102°F. Which intervention should the nurse implement?
- A. Notify the health-care provider.
- B. Prepare to administer a Fleet's enema.
- C. Administer an antipyretic suppository.
- D. Continue to monitor the client closely.
Correct Answer: A
Rationale: A rigid abdomen and fever (102°F) suggest possible perforation or peritonitis, requiring immediate HCP notification for evaluation and possible surgical intervention. Enemas are contraindicated, and antipyretics or monitoring delay critical action.