The nurse is delegating the performance of passive range of motion to the unlicensed assistive personnel (UAP). For which client would it not be appropriate to delegate this task to the UAP?
1. Client who has been a quadriplegic for 3 years
2. Unconscious client following excision of a brain tumor 2 days ago
3. Client in rehabilitation center recovering from a CVA
4. Client in a chronic vegetative state following a motor vehicle crash
Correct Answer: 2
The client who is unconscious following recent brain surgery is at risk for increased intercranial pressure, so passive range of motion should be performed only while constantly assessed for signs of increased pressure. This client could not be safely delegated to a UAP. The remaining clients could be safely delegated to the UAP.
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The nurse records a patient's hourly urine output from an indwelling catheter as follows:
0700: 36 ml 0800: 45 ml 0900: 85 ml 1000: 62 ml 1100: 50 ml 1200: 48 ml 1300: 94 ml 1400: 78 ml 1500: 60 ml The nurse can conclude that the patient's urine output should be described as which of the following? 1) Very low 2) Within normal limits 3) Very high 4) Inconclusive
Six weeks after an above the knee (AKA) amputation, a patient returns to the outpatient office for a routine postoperative check up. During the nurse's assessment, the patient reports symptoms of phantom pain
What would the nurse correctly tell the patient to do to reduce the discomfort of the phantom pain? A) Apply hot compresses to the area of the amputation. B) Avoid rehabilitation exercises until the pain subsides. C) Comfortably increase their level of activity. D) Assess for a pulse in the extremity of the amputation every 4 to 6 hours.
A patient who tested positive for HIV is started on antiretroviral medication
Which outcome would the nurse evaluate as indicating that the goals of this therapy are being met? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient's HIV RNA level has dropped from 100,000 copies/mL to 45,000 copies/mL. 2. The patient's CD4 + T-cell count is 150 cells/mL. 3. The patient has not developed an opportunistic infection. 4. The patient's viral load reveals that the disease is cured. 5. The patient has lost 10 pounds.
The expected competencies of new nursing graduates are not standardized and can vary between institutions and organizations
Most nursing and healthcare organizations, however, agree that recent graduates should be able to use the nursing process in a systematic way. Which of the following nursing activities best exemplifies this competency? A) The nurse identifies a nursing diagnosis of Impaired Skin Integrity based on an assessment and plans to reposition the patient. B) The nurse administers an ACE inhibitor to a patient with high blood pressure. C) The nurse makes a referral to occupational therapy for a patient with a neurological deficit. D) The nurse attends an inservice on pain control that is conducted by a nurse educator.