Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?

Instruct the UAP to ask the visitor to get off the client's bed.

Discuss why visitors should not lie in the bed with the client.

Explain that the client has the right to have a visitor lie on the bed.

Notify the charge nurse that the visitor is lying on the client's bed.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Instructing the UAP to ask the visitor to get off the client's bed is not within the UAP's scope of practice and may cause conflict.

Choice B rationale: While education about infection control and respect for the client's environment is important, it's essential to prioritize the client's autonomy and preferences regarding their visitors.

Choice C rationale: Clients have rights to decide who can be in their personal space, including their bed. As long as the visitor is not posing a risk to the client's safety or health, the client's wishes should be respected.

Choice D rationale: Notifying the charge nurse about the visitor lying on the bed is a reasonable action, but the immediate intervention is to ask the visitor to get off the bed.

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Correct Answer is D

Explanation

Choice A rationale: The client with a kidney transplant experiencing "flu-like" symptoms can be evaluated for urgency but may not require the first available appointment.
Choice B rationale: The client with non-radiating, low-back pain rated at 10 on a scale of 0 to 10 should be assessed, but it may not be an immediate concern compared to the other options.
Choice C rationale: The client at 3-weeks gestation with a small amount of bright red blood after passing stool requires evaluation, but it may not be as urgent as the client in Choice D.
Choice D rationale: The 2-year-old girl with a history of a "cold," tugging on her ear, and a fever of 102 F (38.9° C) may have an ear infection, which could be an acute problem requiring prompt evaluation.

A. Consult with the registered dietitian about recommended nutritional needs. B. Maintain a clean and pleasant environment during meals. C. Set up the food and drink containers within easy reach. D. Offer high caloric foods such as milk and ice cream.

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale: Consulting with the registered dietitian involves clinical judgment and collaboration with another healthcare professional, which is not within the scope of practice for the UAP.

Choice B rationale: Maintaining a clean and pleasant environment during meals is a task that can be delegated to the UAP to enhance the client's dining experience. Choice C rationale: Setting up the food and drink containers within easy reach is a task that the UAP can perform to facilitate the client's access to meals.

Choice D rationale: Offering specific dietary recommendations, such as high-caloric foods, requires knowledge of nutritional needs, which is beyond the UAP's scope. Choice E rationale: Assisting the client with eating small frequent high-calorie meals is a task that can be delegated to the UAP to support the client's nutritional intake.

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Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing telephone triage at the clinic office. Which client has the most acute problem and should be scheduled for the first available appointment?

Correct Answer is D

Explanation

A client is admitted with exacerbation of chronic obstructive pulmonary disease (COPD) and reports that it is difficult to eat due to shortness of breath (SOB). Which task(s) should the nurse delegate to the unlicensed assistant personnel (UAP)? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

The charge nurse of a critical care unit must transfer a client to a general unit to make a bed available for an incoming trauma client. Based on the information provided, which client is best for the nurse to recommend for transfer to the general unit?

Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?

A client with influenza is admitted to the medical unit. The nurse observes an unlicensed assistive personnel (UAP) preparing to enter the client's room to take vital signs and assist with personal care. The UAP has applied gloves and a gown. Which action should the nurse take?

The nurse manager conducts regular audits of patient care medication records and notices that the amount of narcotic pain medications administered during the evening shift on a postsurgical unit is higher than usual. Which action should the nurse manager take first?

A client with life threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?

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