HESI Comprehensive B, Comprehensive Exam A, 2020 exit v 2
The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immedia
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HESI Comprehensive B, Comprehensive Exam A, 2020 exit v 2
The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse?
A.Suctions oral secretions from mouth
B.Positions head of bed flat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees
B
Rationale:
Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D).
When caring for a postsurgical client who has undergone multiple blood transfusions, which serum laboratory finding is of most concern to the nurse?
A.Sodium level, 137 mEq/L
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L
B
Rationale:
Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D).
Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine
A
Rationale:
The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV is not recommended until adolescence (B). Varicella immunization begins at 12 months (C). Meningococcal vaccine is administered beginning at 2 years (D).
The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)?
A.Assess the need to change a central line dressing.
B.Obtain a fingerstick blood glucose level.
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