The charge nurse supervises unlicensed assistive personnel in the post-stroke rehabilitation unit.
Which action by the unlicensed assistive personnel requires immediate intervention by the nurse?

The unlicensed assistive personnel tied the confused client to a chair with a sheet.

The unlicensed assistive personnel escorted the client downstairs to smoke a cigarette.

The unlicensed assistive personnel assisted the client in ambulating to the dayroom area.

The unlicensed assistive personnel bought the client a carbonated beverage from the cafeteria.

Answer and Explanation

The Correct Answer is A

This scenario requires applying knowledge of safety protocols, legal standards for restraint use, and nursing delegation. Understanding that using sheets as makeshift restraints is illegal and dangerous is critical for maintaining patient safety and adhering to healthcare regulations regarding physical interventions.

Choice A rationale

Using sheets as restraints is a violation of safety standards and patient rights. Restraints require a specific medical order and must be manufactured devices. Improper tying can cause skin breakdown, strangulation, or impaired circulation in confused patients.

Choice B rationale

While smoking is generally discouraged in healthcare facilities, escorting a stable patient outdoors does not constitute an immediate safety emergency compared to illegal restraint. It requires a policy review rather than an emergency clinical intervention by the supervisor.

Choice C rationale

Assisting with ambulation is a standard task for unlicensed personnel. In a rehabilitation unit, promoting mobility is a key goal. This action is appropriate unless the patient is specifically designated as bedrest or requires a therapist.

Choice D rationale

Providing a beverage is generally within the scope of unlicensed staff unless the patient is NPO or on a restricted diet. While carbonation may not be ideal, it does not pose an immediate physical threat.

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Correct Answer is B

Explanation

Managing hepatic encephalopathy requires understanding the biochemical role of ammonia in brain toxicity. Knowledge of the enterohepatic circulation and the pharmacological action of osmotic laxatives is necessary to facilitate the excretion of nitrogenous wastes and improve neurological status.

Choice A rationale

Loop diuretics are used to treat ascites or edema but do not directly lower serum ammonia. Excessive diuresis can actually trigger hepatic encephalopathy by causing dehydration and electrolyte imbalances, such as hypokalemia, which increases renal ammonia production and toxicity.

Choice B rationale

Lactulose is a disaccharide that acidifies the colon, converting ammonia into non-absorbable ammonium ions. This osmotic effect also promotes bowel movements, facilitating the rapid excretion of these toxins from the gut, thereby reducing blood ammonia levels and confusion.

Choice C rationale

Restricting fluids does not lower ammonia and can worsen hepatic encephalopathy by causing dehydration and constipation. Adequate hydration and bowel motility are necessary to ensure that nitrogenous wastes are flushed from the gastrointestinal tract effectively to prevent systemic accumulation.

Choice D rationale

Protein breakdown in the gut by bacteria produces ammonia. Increasing protein intake in a client with end stage cirrhosis would likely worsen encephalopathy by providing more nitrogenous substrate for ammonia synthesis, further elevating toxic levels in the blood.

Correct Answer is ["No"]

Explanation

The correct answer is No.

Step 1 is 14 lbs ÷ 2.2 lb/kg = 6.36363636 kg.

Step 2 is 6.36 kg × 20 mg/kg/day = 127.2 mg/day for the minimum safe dose.

Step 3 is 6.36 kg × 30 mg/kg/day = 190.8 mg/day for the maximum safe dose.

Step 4 is 35 mg × (24 hours ÷ 4 hours) = 35 mg × 6 doses = 210 mg/day for the total daily dose.

Step 5 is 210 mg/day > 190.8 mg/day, which exceeds the recommended maximum daily range.

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The charge nurse supervises unlicensed assistive personnel in the post-stroke rehabilitation unit. Which action by the unlicensed assistive personnel requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with end-stage cirrhosis and hepatic encephalopathy becomes increasingly confused and drowsy. Which intervention should the nurse implement to reduce ammonia levels?

Correct Answer is B

Explanation

The physician prescribes ticarcillin 35 mg IV every 4 hours for a client post kidney transplant. The client weighs 14 lbs. The nursing drug reference recommends a maximum of 20-30 mg/kg/day. Is the ordered dose for this client safe? Yes or No.

Correct Answer is ["No"]

Explanation

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The charge nurse supervises unlicensed assistive personnel in the post-stroke rehabilitation unit.
Which action by the unlicensed assistive personnel requires immediate intervention by the nurse?