When walking past a client's room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention?

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Question 1 of 5

When walking past a client's room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention?

Correct Answer: B

Rationale: Would you do this one client's glucose test?' requires intervention. Glucose testing is beyond UAP scope; it's an RN/PN task. Teamwork , monitoring confusion , and bed-making are appropriate. B risks safety, needing RN correction, making it the statement to address.

Question 2 of 5

A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that

Correct Answer: A

Rationale: Fantasies can gratify unconscious wishes or prepare for future events' explains daydreaming. Per psychology, it's a coping mechanism, not dissociation , conversion , or isolation . A fits mental health context, making it the best explanation.

Question 3 of 5

The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?

Correct Answer: D

Rationale: Supervising a nursing assistant for skin care is best. Skin tears need RN oversight, but UAP can assist, unlike total RN care , self-care , or full delegation . D balances skill and safety.

Question 4 of 5

The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the client?

Correct Answer: A

Rationale: Clean the meatus, begin voiding, then catch urine stream' is the correct sequence. Cleaning reduces contamination, initial voiding clears bacteria, midstream collection ensures accuracy, per protocol. Other options (B, C, D) risk contamination. A aligns with standards, making it appropriate.

Question 5 of 5

Which blood serum finding in a client with diabetic ketoacidosis alerts the nurse that immediate action is required?

Correct Answer: A

Rationale: pH below 7.3 alerts for immediate action in DKA. Acidosis (pH <7.35) signals severe metabolic imbalance, needing urgent correction. Potassium , HCT , and PaO2 are secondary. A drives intervention, making it critical.

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