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Questions 148

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Extract:


Question 1 of 5

Which of the following tasks are appropriate for the nurse to delegate to unlicensed assistive personnel? Select all that apply.

Correct Answer: B,C,E

Rationale: Unlicensed assistive personnel can perform routine tasks like checking routine vital signs (
B), measuring urinary output (
C), and assisting with ambulation (E). Checking vital signs in an acutely ill client (
A) and monitoring a transfusion (
D) require a nurse's assessment skills.

Question 2 of 5

The doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows antithrombolic stockings should be applied:

Correct Answer: A

Rationale: Applying antithrombic stockings before rising prevents venous pooling, maximizing their effectiveness in improving circulation.

Question 3 of 5

An elderly female is admitted with a fractured right femoral neck. Which clinical manifestation would the nurse expect to find?

Correct Answer: D

Rationale: A femoral neck fracture typically causes shortening of the affected leg due to muscle contraction pulling the bone fragments together, along with external rotation and limited movement.

Question 4 of 5

The nurse is observing the respirations of a client when she notes that the respiratory cycle is marked by periods of apnea lasting from 10 seconds to 1 minute. The apnea is followed by respirations that gradually increase in depth and frequency. The nurse should document that the client is experiencing:

Correct Answer: A

Rationale: Cheyne-Stokes respirations are characterized by periods of apnea followed by increasing depth and frequency of breaths.

Question 5 of 5

A client has recurrent episodes of constipation and fecal impaction. The nurse is assisting the client with a bowel-training regimen. Which of the following interventions should be included? Select all that apply.

Correct Answer: A,B,C,F

Rationale: Bowel training includes scheduled toileting (
A), stool softeners (
B), high-fiber diet (
C), and routine exercise (F) to promote regular bowel movements. Daily laxatives (
D) and periodic enemas (E) are not preferred long-term.

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