An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client who is prescribed bedrest with bedside commode use. The UAP reports to the nurse that the client's obesity makes it difficult to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond?

Advise the client to maintain bedrest to ensure safety.

Instruct the UAP that all clients deserve equal care.

Determine the client's level of mobility and need for assistance.

Assign another UAP to care for the client.

Answer and Explanation

The Correct Answer is C

Choice A reason: Advising the client to maintain bedrest may not be practical or beneficial for the client's overall health and does not address the UAP's concern about safe transfer.

Choice B reason: While it is true that all clients deserve equal care, this statement does not provide a solution to the UAP's concern about safely assisting the client.

Choice C reason: Determining the client's level of mobility and need for assistance will help in creating a safe and effective plan for transferring the client to the bedside commode.

Choice D reason: Assigning another UAP may be necessary if the current UAP is unable to assist safely, but it is not the first step. The nurse should first assess the situation before making staffing changes.

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Correct Answer is C

Explanation

Choice A reason: Applying a water-soluble lubricant to the catheter is not recommended during tracheostomy suctioning as it may introduce contaminants.

Choice B reason: Instilling sodium chloride before suctioning is not a standard practice and can lead to complications such as edema.

Choice C reason: Wearing protective goggles is important to protect the nurse from potential splashes of bodily fluids during the suctioning process.

Choice D reason: Instructing the client to cough as the suction tip is removed is not recommended as it can cause discomfort and potential harm to the tracheal lining.

A. Activate the lockdown procedure. B. Match ID bands of all infants and mothers on the unit. C. Ask the mother if any visitors were expected to arrive. D. Determine if the newborn is in the nursery.

Correct Answer is A

Explanation

Choice A reason: The immediate activation of the lockdown procedure is critical in the event of a suspected infant abduction, as it helps to secure the facility and prevent the unauthorized removal of the infant.

Choice B reason: Matching ID bands is a standard procedure but not the first action to take in a potential abduction scenario.

Choice C reason: Asking the mother about expected visitors is part of the investigation but does not take precedence over securing the facility.

Choice D reason: Determining if the newborn is in the nursery is important but should follow the immediate security measures.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Correct Answer is C

Explanation

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

Correct Answer is A

Explanation

Patient Data Exhibits The nurse reviews the client data. What discharge education should the nurse provide? Select all that apply.

The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?

Patient Data Exhibits The nurse educates the parents on post discharge care for the child. What should the nurse include in post discharge care education? Select all that apply.

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care?

Patient Data Exhibits After the physician orders the echocardiogram, the nurse educates the parents about the procedure. For each statement below, indicate whether it shows understanding or a lack of understanding by the parents.

Patient Data Exhibits Review H and P and laboratory results. What item(s) should be included in the treatment regimen for this client? Select all that apply.