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Questions 164

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Extract:


Question 1 of 5

The nurse is observing a nursing assistant transfer a client from bed to chair. Which observation needs correction? Select all that apply.

Correct Answer: C,D,E

Rationale: The nursing assistant should stand with feet apart and knees bent to prevent injury, not grab the client's arm, and avoid tugging on the client's arms. Lowering the bed, sitting the client up, and assisting to pivot are correct.

Question 2 of 5

The practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply.

Correct Answer: B,C,D,E

Rationale: Elevating the head of the bed (≥30 degrees) reduces reflux, proper cuff pressure seals the airway, monitoring distension detects feed intolerance, and cautious sedation prevents respiratory depression. Residual checks every 4-6 hours are standard, not 12.

Question 3 of 5

Based on knowledge of cultural diversity, the nurse knows that obtaining a CBC will be most distressing for the client who is:

Correct Answer: D

Rationale: Some Native American cultures believe blood removal weakens the body or spirit, making a CBC distressing. Other groups typically do not have this belief.

Question 4 of 5

The nurse is explaining the effects of cocaine abuse to a pregnant client. Which of the following must the nurse understand as a basis for teaching?

Correct Answer: A

Rationale: Cocaine is vasoconstrictive, and this effect in the placental vessels causes fetal growth retardation.

Question 5 of 5

The nurse caring for multiple clients on a medical-surgical unit should delegate which action to the nursing assistant?

Correct Answer: A

Rationale: Assisting with mobility, such as to the bathroom, is within the nursing assistant's scope. Wound assessment, tube discontinuation, and treating hypoglycemia require nursing judgment and are outside their scope.

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