Question

1-)The following client care activities need to be completed. It would be most appropiate for the nurse to assign UAP:

a) apply a continuous passive motion (CPM) device to the affected extremity of a client who had a total knee replacement

b) change the bed lines for a client who was admitted 1 hour ago following a closed-head injury and is comatose

c) reposition a client with hydrocephalus who has a headache and is vomiting

d) place in the prone position a client who had an above-the-knee amputation (AKA) 1 day ago

2-) The nurse is planning a staff education conference about infection control guidelines. Which of the following information about alcohol-based hand rub should the nurse include?

a) Use before touching medical equipment that will come in direct contact with the client

b) Avoid using when moving your hands from contaminated body site to a clean body site during client care

c) Avoid using before caring for clients who have severe neutropenia

d) Use after contact with body excretions that do not cause your hands to be visible soiled

3- The nurse should assess first?

a) Acute lymphoid Leukemia(ALL) whose temperature has changed from 99 F to 100.8 F

b) diabetes mellitus (type 1) whose capillary blood glucose level is 275 mg/dL

c) End- Stage renal Disease (ESRD) who had a urinary output of 2 mL during past hour

d) Chronic Obstructive pulmonary disease(COPD) whose respirations are 24

4- The nurse has attended a staff education conference about caring for clients who are receiving positive-pressure mechanical ventilation. Which of the following statements by the nurse would indicate a correct understanding of the teaching?

a) Client should avoid range-of -motion (ROM) exercises until weaned from ventilation

b) Clients may develop stress ulcers and gastrointestinal bleeding

c) Client will be chemically paralyzed to improve oxygenation

d) Clients will experience diuresis and polyuria

5- The nurse should first asses the client:

a) who had a right pneumonectomy 24 hours ago and is in the high-Flower's position while lying on the right side

b) with COPD who is using pursed-lip breathing and reporting hemoptysis

c) who had a wedge resection of the left lung 24 hours ago and is sitting in the high-flowers position

d) with heart failure who has a productive cough and is restless

Answer 1

1.Unlicensed assistive personnel can do the basic procedures like meeting personal hygiene of the patient ,changing linen, positioning, backcare.

CPM for the first time after surgery ideally will be applied by a physical therapist

A patient with headache and vomiting should be be repositioned unless a recovery position is needed to prevent aspiration rather needed medical help from RN for pain and vomiting

A post operative patient generally will not be recommended to be placed in probe position if to be done needs a supervision

Ans:change the bed linens for the client who was admitted one hour ago following a closed head injury and is comatose

2.Follow five moments if hand hygiene (before touching patient, patient surrounding , equipment) to prevent cross infection

Should be used when moving from contaminated to clean area to prevent transmission of microorganisms

A neutropenea patient is low in immunity so it is a must to use handgun to prevent cross infection

It is better to used soap and water after touch body excretion

Ans:Use before touching the medical equipment that will come in direct contact with the patient

3.A patient whose body temperature rose to 100.8 F needs immediate interventions to reduce body temperature

A 275mg/dl of blood glucose can be found in most type diabetic patient

In ESRD patient there may or may not be urine output

In COPD patient 24 breath is normal

Ans:Acute lymphoid leukemia whose temperature has changed from 99 to 100.8 F

4. Passive range of motion exercises can be done in these patients to prevent musculoskletal issues,other complications and improve body functions

Chemical paralysis is not recommended to improve oxygenation

Stress ulcer is most common in these patients

Fireside can be a complication of medications or body functions bit not due to mechanical ventilation

Ans:clients may develop stress ulcer and gastrointestinal bleeding