What can be delegated to Assistive personnel (AP)?
- ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow
precautions) - positioning - bed making - specimen collection - I&O - VS (stable
clients
A
...
What can be delegated to Assistive personnel (AP)?
- ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow
precautions) - positioning - bed making - specimen collection - I&O - VS (stable
clients
A nurse on a med surg unit has recieved change of shift report and will care for 4
clients. Which of the following clients needs will the nurse assign to an AP?
A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
B. Reinforcing teaching with a client who is learning to walk with a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer
C
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days
ago to an AP. Which of the following info should the nurse share with the AP?
Select all:
A. the roommate is up independently
B. The client ambulates with his slippers on over his antiembolic stockings
C. The client uses a front wheeled walker when ambulating
D. The client had pain meds 30 minutes ago
E. The client is allergic to codeine
F. the client ate 50 % of his breakfast this morning
BCD
An RN is making assignments for client care to an LPN at the beginning of the
shift. Which of the following assignments should the LPN question?
A. Assisting a client who is 24 hr postop to use an incentive spirometer
B. Collecting a clean catch urine specimen from a client who was admitted on the
previous shift
C. providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a PCA pumpD
A nurse is preparing an inservice program about delegation. Which of the
following elements should she identify when presenting the 5 rights of delegation.
Select all:
A. Right client
B. Right supervision/evaluation
C. Right direction/communication
D. Right time
E. Right circumstances
BCE
A nurse manager of a med surg unit is assigning care responsibilities for the
oncoming shift. A client is waiting transfer back to the unit from the PACU
following thoracic surgery. To which staff member should the nurse assign the
client?
A. Charge nurse
B. RN
C. LVN
D. AP
B
What is the study of conduct and character?
Ethics
What are the values and beliefs that guide behavior and decision making?
Morals
What is the right to make ones own personal decisions, even tho those decisions
might not be in the persons best interest
Autonomy
What are positive actions to help others
Beneficience
What is an agreement to keep promisesFidelity
What is fairness in care delivery and use of resources
Justice
What is avoidance of harm or injury
Non-maleficence
A nurse is caring for a client who decides not to have surgery despite significant
blockages in his coronary arteries. The nurse understands that this clients choice is
an example of what principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmalificience
B
A nurse offers pain meds to a client who is postop prior to ambulation. The nurse
understands that this aspect of care delivery is an example of which of the
following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Beneficience
D
A nurse is instructing a group of nursing students about the responsibilities
involved with organ donation and procurement. When the nurse explains that all
clients waiting for a kidney transplant have to meet the same qualifications, the
students should understand that this aspect of care delivery is an example of which
ethical principle
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence
CA nurse questions a med prescription as too extreme and light of the clients
advanced age and unstable status. The nurse understands that this action is an
example of which ethical principle
A. Fidelity
B. Autonomy
C. Justice
D. Nonmalificence
D
Which of the following situations can be identified as an ethical dilemma?
A. A nurse on a med surg unit demonstrates signs of chemical impairment
B. A nurse over hears another nurse telling an older adult client that if he doesnt
stay in bed she will restrain him
C. A family has conflicting feelings about the initiation of enteral tube feedings of
their father who is terminally ill
D. A client who is terminally ill hesitates to name her spouse on her durable power
of attorney form
C
Most managers can be categorized as
authoritative, democratic, and laissez faire
makes decisions of the group
motivates by coercion
communication occurs down the chain of command
Work output by the staff is usually high-good for crisis situations and bureaucratic
settings
Authoritative
includes the group when decisions are made
Motivates by supporting star achievements
Communication occurs up and down the chain of command
Work output by staff is usually of good quality-good when cooperation and
collaboration is necessary
Democraticmakes very few decisions and does little planning
motivation is largely the responsibility of individuals staff members
Communication occurs up and down the chain of command and between group
members
Work output is low unless an informal leader evolves from the group
*the use of any of these styles may be appropriate depending on the situation
Laissez faire
The nurse should consider the hierarchy of human needs when prioritizing
interventions, which are?
- Physiological needs first (oxygen, shelter, food)
- Safety & security needs (physical safety)
- Love and belonging
- Self esteem
- Self actualization
The ABC framework identifies, in order, the three basic needs for sustaining life
Airway
Breathing
Circulation
Nurses must follow what code of standards in delegating and assigning tasks
ANA codes of standards
What values would a nurse possess to be a client advocate?
- caring
- autonomy
- respect
- empowerment
What do the nurse need to keep in mind about the client when being their
advocate?
Client's religion & culture
When should planning discharge process begin?
a. at time of admission
b. 2 days after client is admittedc. whenever the nurse has the time to do planning
d. when the physician has the discharge order
A
What is an interdisciplinary team?
A group of health care professionals from different disciplines
Fill in the blank:
1. _______ is used by interdisciplinary team to make health care decisions about
clients with multiple problems. 2. ________, which may take place at team
meetings, allows the achievement of results that the participants would be
incapable of accomplishing if working alone.
1 & 2 = collaboration
What is the nurse's contribution to an interdisciplinary team?
- knowledge of nursing care & its management
- a holistic understanding of the client, her/his healthcare needs & healthcare
systems.
A four-month-old infant is admitted to the pediatric intensive care unit
with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse
observes nuchal rigidity. Which assessment finding would indicate an
increase in intracranial pressure?
1. Positive Babinski.
2. High-pitched cry.
3. Bulging posterior fontanelle.
4. Pinpoint pupils.
2
A client is receiving total parenteral nutrition (TPN). To determine the
client's tolerance of this treatment, the nurse should assess for which of the
following?
1. A significant increase in pulse rate.
2. A decrease in diastolic blood pressure.
3. Temperature in excess of 98.6°F (37°C).
4. Urine output of at least 30 cc per hour.
4The client is exhibiting symptoms of myxedema. The nursing
assessment should reveal
1. increased pulse rate.
2. decreased temperature.
3. fine tremors.
4. increased radioactive iodine uptake level.
2
A nonstress test is scheduled for a client at 34-weeks gestation who
developed hypertension, periorbital edema, and proteinuria. Which of the
following nursing actions should be included in the care plan in order to
BEST prepare the client for the diagnostic test?
1. Start an intravenous line for an oxytocin infusion.
2. Obtain a signed consent prior to the procedure.
3. Instruct client to push a button when she feels fetal movement.
4. Attach a spiral electrode to the fetal head.
3
Which of the following nursing interventions is MOST important for a
45-year-old woman with rheumatoid arthritis?
1. Provide support to flexed joints with pillows and pads.
2. Position her on her abdomen several times a day.
3. Massage the inflamed joints with creams and oils.
4. Assist her with heat application and ROM exercises.
4
The nurse is caring for a young adult admitted to the hospital with a
severe head injury. The nurse should position the patient
1. with his neck in a midline position and the head of the bed elevated 30°.
2. side-lying with his head extended and the bed flat.
3. in high Fowler's position with his head maintained in a neutral position.
4. in semi-Fowler's position with his head turned to the side.
1
The nurse is teaching a 40-year-old man diagnosed with a lower motor
neuron disorder to perform intermittent self-catheterization at home. The
nurse should instruct the client to1. use a new sterile catheter each time he performs a catheterization.
2. perform the Valsalva maneuver(holding breath and bearing down) before doing
the catheterization.
3. perform the catheterization procedure every 8 hours.
4. limit his fluid intake to reduce the number of times a catheterization is needed.
2
A client is being discharged with sublingual nitroglycerin (Nitrostat).
The client should be cautioned by the nurse to
1. take the medication five minutes after the pain has started.
2. stop taking the medication if a stinging sensation is absent.
3. take the medication on an empty stomach.
4. avoid abrupt changes in posture.
4
A 38-year-old woman is returned to her room after a subtotal
thyroidectomy for treatment of hyperthyroidism. Which of the following, if
found by the nurse at the patient's bedside, is nonessential?
1. Potassium chloride for IV administration.
2. Calcium gluconate for IV administration.
3. Tracheostomy set-up.
4. Suction equipment.
1
A nurse recognizes that an initial positive outcome of treatment for a
victim of sexual abuse by one parent would be that the client
1. acknowledges willing participation in an incestuous relationship.
2. reestablishes a trusting relationship with his/her other parent.
3. verbalizes that s/he is not responsible for the sexual abuse.
4. describes feelings of anxiety when speaking about sexual abuse.
3
An adolescent client is ordered to take tetracycline HCL (Achromycin)
250 mg PO bid. Which of the following instructions should be given to this
client by the nurse?
1. "Take the medication on a full stomach, or with a glass of milk."
2. "Wear sunscreen and a hat when outdoors."3. "Continue taking the medication until you feel better."
4. "Avoid the use of soaps or detergents for two weeks."
2
After a client develops left-sided hemiparesis from a cerebral vascular
accident (CVA), there is a decrease in muscle tone. Which of the following
nursing diagnoses would be a priority to include in his care plan?
1. Alteration in mobility related to paralysis.
2. Alteration in skin integrity related to decrease in tissue oxygenation.
3. Alteration in skin integrity related to immobility.
4. Alteration in communication related to decrease in thought processes
2
A client has a history of oliguria, hypertension, and peripheral edema.
Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be
restricted in the client's diet?
1. Protein.
2. Fats.
3. Carbohydrates.
4. Magnesium.
1
An extremely agitated client is receiving haloperidol (Haldol) IM every
30 minutes while in the psychiatric emergency room. The MOST important
nursing intervention is to
1. monitor vital signs, especially blood pressure, every 30 minutes.
2. remain at the client's side to provide reassurance.
3. tell the client the name of the medication and its effects.
4. monitor the anticholinergic effects of the medication.
1
The nurse is caring for clients in the skilled nursing facility. Which of the
following clients require the nurse's IMMEDIATE attention?
1. A client admitted for a cerebral vascular accident (CVA) whose prescription for
warfarin (Coumadin) expired two days ago.
2. A client in pain who was receiving morphine in an acute care institution and was
transferred with a prescription for acetaminophen with codeine
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