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Which tasks are appropriate for the nurse in a long-term care unit to delegate to unlicensed assistive personnel? Select all that apply.
- A. Assign lunch times to other unlicensed assistive personnel on the unit
- B. Assist a client with bathing and changing an ostomy appliance
- C. Collect vital signs on a client newly arrived on the unit
- D. Pick up a prescribed oral antibiotic from the pharmacy
- E. Record intake and output for a client with chronic neurogenic bladder
Correct Answer: C,E
Rationale: Collecting vital signs and recording intake/output are within the scope of unlicensed assistive personnel. Other tasks require nursing judgment or are outside their scope.
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The daughter of a 78-year-old woman asks the nurse why her mother is giving away some of her belongings to her children and grandchildren. What should the nurse include when responding?
- A. Older adults usually become more generous.
- B. It is normal for older adults to think about and prepare for their own death.
- C. Her mother probably does not trust her children to divide her things appropriately.
- D. Her mother is probably thinking about suicide.
Correct Answer: B
Rationale: Giving away belongings reflects preparation for death, a normal developmental task in older adults achieving ego integrity. Generosity, distrust, or suicide are less likely.
A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. The appropriate initial action should be to
- A. Begin mouth to mouth resuscitation
- B. Give the child water to help in swallowing
- C. Perform 5 abdominal thrusts
- D. Call for the emergency response team
Correct Answer: C
Rationale: Perform 5 abdominal thrusts. This is the most effective method to clear a food obstruction in a toddler.
Which of the following indicates failure of a ventriculoperitoneal shunt?
- A. Projectile vomiting
- B. Abdominal distention
- C. Decreased urinary output
- D. Hemodilution
Correct Answer: A
Rationale: Projectile vomiting is a sign of increased intracranial pressure due to ventriculoperitoneal shunt failure, indicating obstruction or malfunction.
The nurse makes a home visit to a client with Alzheimer disease. While reviewing the client's home care needs, the client's spouse states, 'It's hard to see my spouse worsen each day. I'm not sure I can keep doing this alone anymore.' Which response by the nurse is best?
- A. Perhaps finding a caregiver to care for your spouse at night might be helpful.
- B. Tell me about the care you provide in a typical day and its challenges.
- C. Try not to worry. It's normal to feel overwhelmed when you are stressed.
- D. You seem worried that you won't be able to provide the care that your spouse needs.
Correct Answer: B
Rationale: Exploring the spouse's daily challenges encourages open communication and helps identify specific support needs.
An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by
- A. Tachypnea
- B. Acidic byproducts
- C. Aspirin poisoning and dehydration
- D. Hyperpyrexia
Correct Answer: A
Rationale: Tachypnea. Stimulation of respiratory center leads to hyperventilation, thus decreasing CO2 levels which causes respiratory alkalosis.