Nokea
Which tasks can the licensed practical nurse appropriately delegate to unlicensed assistive personnel? Select all that apply.
- A. Assist the nurse in ambulating a client 1 day post abdominal surgery
- B. Measure and empty drainage output into a bulb drain
- C. Monitor for redness and swelling at a client’s IV insertion site
- D. Provide extra blankets at the client’s request
- E. Take family members to the waiting room after a client goes into surgery
Correct Answer: A,B,D,E
Rationale: Assisting with ambulation, measuring drainage, providing blankets, and escorting family are within UAP scope with proper training. Monitoring IV sites requires nursing judgment and is not delegable.
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A client who is blind is admitted to the hospital for surgery tomorrow. The client is able to get out of bed and eat until midnight. Which nursing action is most appropriate?
- A. Describe the surroundings and the objects in the room to the client.
- B. Put up the side rails and have the client ask for help when getting out of bed for any reason.
- C. Describe the voices of the personnel to the client.
- D. Remove objects such as water pitchers and glasses from the immediate vicinity.
Correct Answer: A
Rationale: Describing surroundings aids orientation and safety for a blind client, promoting independence. Side rails, voice descriptions, or removing objects are less helpful.
The nurse is assessing a client who had a left arm cast applied four hours ago. Which finding indicates that the client may have circulatory impairment?
- A. The client's nail beds blanch when the nurse applies pressure; color returns in two seconds.
- B. The client's fingers on the left hand are cold to the touch.
- C. The client complains of pain at the fracture site.
- D. The client is unable to move the fingers on the left hand.
Correct Answer: B
Rationale: Cold fingers suggest impaired circulation in the casted arm, indicating potential compartment syndrome or vascular compromise, requiring immediate evaluation. Normal blanching, fracture pain, or immobility are less specific.
The nurse is talking to a client with a newly diagnosed seizure disorder who has a prescription for levetiracetam. Which of the following statements by the client would require follow-up?
- A. I can begin driving my car again after I have been taking this medication for 2 weeks
- B. I need to contact my health care provider if I develop a rash while taking this medication
- C. I should report any new or increased anxiety I experience while taking this medication
- D. I understand that drowsiness is an adverse effect of this medication that may improve over time.
Correct Answer: A
Rationale: Driving restrictions for seizure disorders typically last 6-12 months seizure-free, not 2 weeks, posing a safety risk. Reporting rashes and anxiety are correct due to potential side effects of levetiracetam.
What nursing action is essential when oxygen is ordered for a client who is living at home?
- A. Assist the client and family in checking all electrical appliances in the vicinity for frayed cords.
- B. Encourage the client and family to purchase fire extinguishers.
- C. Remove electrical devices from the room where oxygen is in use.
- D. Encourage the client and family to carpet the client's room.
Correct Answer: A
Rationale: Checking for frayed cords reduces fire risk, as oxygen supports combustion. Extinguishers are secondary, removing devices is impractical, and carpeting increases static sparks.
The nurse in an outpatient clinic is caring for a client at 34 weeks gestation. The client is taking ferrous sulfate for anemia and reports constipation. Which of the following recommendations should the nurse reinforce for this client? Select all that apply.
- A. Decreased daily intake of dairy products
- B. Increased intake of fruits and vegetables
- C. Moderate-intensity exercise regularly
- D. One stimulant laxative daily for a week
- E. Two cups of hot coffee each morning
Correct Answer: B,C
Rationale: Fruits and vegetables provide fiber, and exercise promotes bowel motility, relieving constipation. Dairy may worsen constipation, stimulant laxatives are not first-line in pregnancy, and coffee is not a primary solution.