RN COMPREHENSIVE PREDICTORNURSING - STUDY GUIDE

RN COMPREHENSIVE PREDICTORNURSING - STUDY GUIDE What can be delegated to Assistive personnel (AP)? - ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow precautions) - positioning - bed making - s ...

RN COMPREHENSIVE PREDICTORNURSING - STUDY GUIDE 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 (stableclients A nurse on a med surg unit has recieved change of shift report and will care for 4clients. 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 caneC. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcerC A nurse is delegating the ambulation of a client who had knee arthroplasty 5 daysago 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 stockingsC. 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 B C D An RN is making assignments for client care to an LPN at the beginning of theshift. 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 theprevious shift C. providing nasopharyngeal suctioning for a client who has pneumoniaD. 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 B C E 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 theclient? A. Charge nurseB. 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 decisionsmight 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 resourcesJustice What is avoidance of harm or injuryNonmaleficence 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 isan example of what principles? A. Fidelity B. Autonomy C. Justice D. NonmalificienceB A nurse offers pain meds to a client who is postop prior to ambulation. The nurseunderstands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. BeneficienceD 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 whichethical principle A. Fidelity B. Autonomy C. Justice D. NonmaleficenceCA 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 anexample of which ethical principle A. Fidelity B. Autonomy C. Justice D. NonmalificenceD 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 doesntstay in bed she will restrain him C. A family has conflicting feelings about the initiation of enteral tube feedings oftheir father who is terminally ill D. A client who is terminally ill hesitates to name her spouse on her durable powerof 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 bureaucraticsettings 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 groupmembers 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 situationLaissez faire The nurse should consider the hierarchy of human needs when prioritizinginterventions, 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 lifeAirway Breathing Circulation Nurses must follow what code of standards in delegating and assigning tasksANA 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 theiradvocate? 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 orderA What is an interdisciplinary team? A group of health care professionals from different disciplinesFill 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 & healthcaresystems. 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 nurseobserves 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 thefollowing? 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 thefollowing 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 a45-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 asevere 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. Thenurse 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 doingthe 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