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Terms in this set (100)
The nurse is caring for a client with a cerebrovascular B
accident (CVA) who is receiving enteral tube feedings. Rationale:
Which task performed by the UAP requires immediate Positioning the head of the bed flat when enteral feedings are in progress puts
intervention by the nurse? the client at risk for aspiration (B). The others are all acceptable tasks
A.Suctions oral secretions from mouth performed by the UAP (A, C, and D).
B.Positions head of bed flat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees
When caring for a postsurgical client who has B
undergone multiple blood transfusions, which serum Rationale:
laboratory finding is of most concern to the nurse? Multiple blood transfusions are a risk factor for hyperkalemia. A serum
A.Sodium level, 137 mEq/L potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The others
B.Potassium level, 5.5 mEq/L are normal findings (A, C, and D).
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L
Which vaccination should the nurse administer to a A
newborn? Rationale:
A.Hepatitis B The hepatitis B vaccination should be given to all newborns before hospital
B.Human papilloma virus (HPV) discharge (A). HPV is not recommended until adolescence (B). Varicella
C.Varicella immunization begins at 12 months (C). Meningococcal vaccine is administered
D.Meningococcal vaccine beginning at 2 years (D).
The nurse is caring for a client on the medical unit. B
Which task can be delegated to unlicensed assistive Rationale:
personnel (UAP)? Obtaining a fingerstick blood glucose level is a simple treatment and is an
A.Assess the need to change a central line dressing. appropriate skill for UAP to perform (B). (A, C, and D) are skills that cannot be
B.Obtain a fingerstick blood glucose level. delegated to UAP.
C.Answer a family member's questions about the
client's plan of care.
D.Teach the client side effects to report related to the
current medication regimen.
The nurse is caring for a client with an ischemic stroke B,C,E
who has a prescription for tissue plasminogen activator Rationale:
(t-PA) IV. Which action(s) should the nurse expect to Neurologic assessment, including the NIHSS, is indicated for the client
implement? (Select all that apply.) receiving t-PA. This includes close monitoring for bleeding during and after the
A.Administer aspirin with tissue plasminogen activator infusion; if bleeding or other signs of neurologic impairment occur, the infusion
(t-PA). should be stopped (B, C, and E). Aspirin is contraindicated with t-PA because it
B.Complete the National Institute of Health Stroke increases the risk for bleeding (A). The administration of t-PA within 6 hours of
Scale (NIHSS). symptoms is concurrent with a diagnosis of a myocardial infarction and within
C.Assess the client for signs of bleeding during and 4.5 hours of symptoms is concurrent for a stroke (D).
after the infusion.
D.Start t-PA within 6 hours after the onset of stroke
symptoms.
E.Initiate multidisciplinary consult for potential
rehabilitation.
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, Students
also
studied
Terms in this set (100)
The nurse is caring for a client with a cerebrovascular B
accident (CVA) who is receiving enteral tube feedings. Rationale:
Which task performed by the UAP requires immediate Positioning the head of the bed flat when enteral feedings are in progress puts
intervention by the nurse? the client at risk for aspiration (B). The others are all acceptable tasks
A.Suctions oral secretions from mouth performed by the UAP (A, C, and D).
B.Positions head of bed flat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees
When caring for a postsurgical client who has B
undergone multiple blood transfusions, which serum Rationale:
laboratory finding is of most concern to the nurse? Multiple blood transfusions are a risk factor for hyperkalemia. A serum
A.Sodium level, 137 mEq/L potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The others
B.Potassium level, 5.5 mEq/L are normal findings (A, C, and D).
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L
Which vaccination should the nurse administer to a A
newborn? Rationale:
A.Hepatitis B The hepatitis B vaccination should be given to all newborns before hospital
B.Human papilloma virus (HPV) discharge (A). HPV is not recommended until adolescence (B). Varicella
C.Varicella immunization begins at 12 months (C). Meningococcal vaccine is administered
D.Meningococcal vaccine beginning at 2 years (D).
The nurse is caring for a client on the medical unit. B
Which task can be delegated to unlicensed assistive Rationale:
personnel (UAP)? Obtaining a fingerstick blood glucose level is a simple treatment and is an
A.Assess the need to change a central line dressing. appropriate skill for UAP to perform (B). (A, C, and D) are skills that cannot be
B.Obtain a fingerstick blood glucose level. delegated to UAP.
C.Answer a family member's questions about the
client's plan of care.
D.Teach the client side effects to report related to the
current medication regimen.
The nurse is caring for a client with an ischemic stroke B,C,E
who has a prescription for tissue plasminogen activator Rationale:
(t-PA) IV. Which action(s) should the nurse expect to Neurologic assessment, including the NIHSS, is indicated for the client
implement? (Select all that apply.) receiving t-PA. This includes close monitoring for bleeding during and after the
A.Administer aspirin with tissue plasminogen activator infusion; if bleeding or other signs of neurologic impairment occur, the infusion
(t-PA). should be stopped (B, C, and E). Aspirin is contraindicated with t-PA because it
B.Complete the National Institute of Health Stroke increases the risk for bleeding (A). The administration of t-PA within 6 hours of
Scale (NIHSS). symptoms is concurrent with a diagnosis of a myocardial infarction and within
C.Assess the client for signs of bleeding during and 4.5 hours of symptoms is concurrent for a stroke (D).
after the infusion.
D.Start t-PA within 6 hours after the onset of stroke
symptoms.
E.Initiate multidisciplinary consult for potential
rehabilitation.
