Lesson 1: Coordinated Care
Information about case management and the role of the case management nurse is presented during an orientation session for new nurses. Which statement correctly describes an important fact about case management? A. Case management is a collaborative process designed to meet complex client needs. B. Case management strategies focus mainly on the client's needs after discharge. C. Physicians are responsible and accountable for client outcomes. D. The interdisciplinary team makes all the decisions for the client and family.
Correct Answer: A Rationale: Case management is a collaborative process of organizing and coordinating resources and services within and across multiple settings. The focus is on cost-savings as well as quality and continuity of care. Case management nurses work closely with physicians, nurses, social workers to meet the complex health needs of the client. Case management is "client-centric" and all members of the team, including the client, work together to achieve desired outcomes. Cases that involve high-risk diagnoses (such as HIV/AIDS, cancer or people with cognitive deficits) or high-volume cases (such as total hip or total knee replacements) are often selected for case management.
A nurse must use an interpreter to collect data from a client. Which action should the nurse take to help communicate with the client? A. Face the client while asking questions as the interpreter translates the information B. Speak directly to the interpreter while asking questions C. Include a family member and direct comments to that person D. Talk to the interpreter in advance and leave the client and interpreter alone for discussion
Correct Answer: A Rationale: Communication is important, especially when the nurse and client do not share the same cultural heritage. Even if the nurse uses an interpreter, it is critical that the nurse use conversational style and spacing, personal space, eye contact, touch, and orientation to time strategies that are acceptable to the client. Therefore, the nurse should face the client and allow the interpreter to translate the content. Facing the client allows nonverbal communication to take place between the client and nurse. Notice that only one option includes the content of this question (collecting data from a client). The other options focus on the "interpreter or the family." Usually, the client-centered option is the best choice.
The LPN/VN assists the RN in evaluating the plan of care for clients. What action does the LPN focus on during the evaluation phase? A. Achievement or status of progress related to prior goals B. Selection of interventions that are measurable and achievable C. Establishment of goals to ensure continuity of care D. Identification of any findings of physical and psychosocial stressors
Correct Answer: A Rationale: Evaluation process of the clinical problem-solving process (the nursing process) should focus on the clients' status, progress toward goal achievement and ongoing re-evaluation of the plan of care. LPN/VN's gather, observe, record and communicate client responses to nursing interventions.
Upon completing a review of a 27-year-old client's admission documents, the nurse identifies that the client does not have an advance directives. What action should the nurse take? A. Inform the charge nurse to offer information about advance directives. B. Refer this issue to the client's health care provider. C. Lecture the client on the importance of having advance directives. D. Advance directives are not appropriate for this client due to the client's age.
Correct Answer: A Rationale: For every admission, the nurse should check if the client has advance directives and if yes, that a copy of the current advance directive is in the medical record. If there are none, the nurse should inform the appropriate interdisciplinary team member to provide information to the client. In most health care settings, nurses, social services, case managers or the spiritual support team can educate clients on advance directives, including helping them complete an advance directive. Every adult client should have advance directives. The client is 27-years-old and is therefore considered an adult.
A LPN complains to the charge nurse that an unlicensed assistive person (UAP) consistently leaves the work area untidy and does not restock supplies. What is the best initial response by the charge nurse? A. Explore for further identification about the nature of the problem B. Assure the staff nurse that the complaint will be investigated C. Write down potential solutions to the problems today by shift's end D. Add this concern to the agenda of the next unit meeting
Correct Answer: A Rationale: Helping staff manage conflict is part of the charge nurse's role. It is appropriate to work with the LPN in order to work out problems with minimal intervention from administration when possible. Further definition of the problem and associated issues would be a first step. The nursing process can be used to collect more data before plans or interventions are made.
A client with a musculoskeletal disorder has been newly fitted with a lower limb orthotic. Which activity can the nurse delegate to the certified nursing assistant (CNA)? A. Assist with transferring the client from the bed to the chair. B. Check the client's skin for any redness or irritation from the orthotic. C. Monitor the client's response to moving with the orthotic. D. Provide instruction to the client for ambulation with the orthotic.
Correct Answer: A Rationale: The CNA (i.e., UAP) can assist with routine activities of daily living, including transferring clients from a bed to a chair or wheelchair. When performed correctly, these routine tasks usually have a predictable outcome. Checking the client's skin involves assessment and monitoring the client's response requires evaluation, both of which are nurse-only activities. A physical therapist would teach the client how to ambulate with an orthotic.
The nurse is caring for a client with congestive heart failure. Which task can the nurse delegate to the unlicensed assistive person (UAP)? A. Record and report the client's intake and output. B. Evaluate understanding of prescribed medications. C. Palpate for edema in the lower extremities. D. Inspect and report peripheral IV site status.
Correct Answer: A Rationale: The nurse is always responsible for any type of physical, social, emotional or environmental assessment. The nurse must assess the client for edema and also any learning needs the client may have. Furthermore, the nurse would also need to assess the status of an IV site for complications such as infiltration or phlebitis. The UAP is able to assist in direct client care activities such as bathing, ambulating, feeding, obtaining vital signs and recording intake and output.
A client with Parkinson's disease is prescribed benztropine (Cogentin). For which of the following should the nurse call the health care provider immediately? A. The client has a history of primary angle-closure glaucoma. B. The client is exhibiting bradykinesia and slurred speech. C. The client's heart rate increased from 80 to 95 beats per minute. D. The client is complaining of dizziness when standing up.
Correct Answer: A Rationale: The nurse must be able to recognize adverse drug effects and contraindications of medications commonly prescribed for the client with Parkinson's disease. Common clinical manifestations of Parkinson's disease include bradykinesia (slow movement), dysarthria (slurred speech) and orthostatic hypotension, caused by the loss of the neurotransmitter dopamine. The goal of pharmacotherapy is to restore the functional balance of dopamine and acetylcholine. This is achieved by giving dopaminergic drugs and cholinergic blockers. Benztropine is an anticholinergic medication used in the treatment of Parkinson's disease that blocks excess cholinergic stimulation in the brain and reduces muscular tremors and rigidity. Tachycardia is a potential adverse drug event, but a heart rate increase of 15 bpm is within acceptable limits. Due to their blocking actions of the parasympathetic nervous system, anticholinergics are contraindicated with glaucoma, where they can cause an increase in intraocular pressure (IOP), which can lead to vision loss and blindness.
The client requests not to be interrupted before 10 am because it interferes with the client's time to meditate. What action shall the nurse take first? A. Meet with the client to formulate a mutually agreeable schedule. B. Notify the dietary department about the client's request. C. Adjust administration times for prescribed medications. D. Document the client's request in the medical record.
Correct Answer: A Rationale: The nurse should communicate with the client to help determine how their meditation practice can be incorporated into the morning schedule. This is the first step in the nursing process and will help the nurse develop an individualized plan of care that incorporates respect for the client's personal choices and preferences.
A home health nurse is providing care for a client. Which client statement should the nurse report immediately to the client's health care provider? A. "When I emptied my urine catheter drainage bag it looked like rusty-colored water." B. "I really don't want home-delivered meals any longer. I am just not hungry." C. "I just didn't sleep well the last few nights. I keep having sad thoughts running through my mind." D. "My neighbors just don't visit me anymore since I came home from the hospital."
Correct Answer: A Rationale: The change in the color of urine to "rusty" suggests blood, a potential sign of an infection or other urinary-renal complication. This requires immediate reporting, documentation and further assessment. The other statements do not require immediate interventions, but should also be addressed as they could indicate depression, social isolation or an underlying, undiagnosed physical problem.
The nurse asks another staff nurse to sign for wasting a partial-dose opioid injection, although the wasting was not witnessed by anyone. This type of request seems to be a pattern of behavior for this nurse. What is the most appropriate action for the second staff nurse to take? A. Report this request immediately to the nurse manager. B. Review the client's medication administration record (MAR) for past wastes. C. Ask the nurse's client if they witnessed the waste of the partial dose. D. Confront the nurse about suspected narcotics diversion.
Correct Answer: A Rationale: The incident must be reported to the appropriate supervisor, either the charge nurse or the nurse manager, for both ethical and legal reasons. This is not an incident that a nurse can resolve without referring to an appropriate authority. The second nurse should only sign as a witness to the wasting of a controlled substance if the nurse actually observed the wasting. Signing as a witness without having actually witnessed the wasting action can be considered falsification of records and result in disciplinary action by the nurse's employer and the state board of nursing.
The nurse is assigned to care for several clients on the day shift. Which client should the nurse see first after receiving shift report? A. The client with asthma who is scheduled for a chest X-ray prior to discharge B. The client with peptic ulcer disease who has been vomiting most of the night C. The client with chronic kidney disease who completed peritoneal dialysis two hours ago D. The client with pancreatitis who reports pain at a level of eight out of 10
Correct Answer: B Rationale: A client with a peptic ulcer who has been vomiting a lot might be experiencing perforation of the ulcer, which is a life-threatening situation that requires emergency surgery. The client with the peptic ulcer should be checked first and findings reported to the charge nurse and/or health care provider.
The nurse observes another nurse walking away from their computer with a client's electronic medical record (EMR) still visible on the screen. What should the nurse do first? A. Speak with the nurse about always closing the EMR. B. Walk over to the computer and close the client's medical record. C. Complete an incident report about the potential client privacy violation. D. Notify the nurse manager of the incident.
Correct Answer: B Rationale: All of the nurse's actions are appropriate, but in order to prevent unauthorized personnel from seeing any of the client's protected health information, the nurse should first close the client's EMR, which is still visible on the screen.
A client refuses to take the medication prescribed because the client prefers to take an herbal preparation instead. What is the first action the nurse should take? A. Explain the importance of the medication to the client B. Discuss with the client to find out about the preferred herbal preparation C. Contact the client's health care provider about the refusal D. Report the behavior to the charge nurse
Correct Answer: B Rationale: Remember, the collection of additional data is typically the initial approach when problems arise. Although the client has the right to refuse the medication, it's possible that the herbal preparation does not have the intended purpose of the prescribed medication or may even have unintended side effects.
The licensed practical nurse (LPN) is reassigned to work on an acute care unit. Which of these clients would be most appropriate for the LPN to accept? A. A trauma victim with multiple lacerations requiring complex dressings B. A confused client whose family complains about the nursing care given after the client's surgery C. A client, admitted for a possible stroke, with unstable neurological findings D. An older adult client diagnosed with cystitis who has an indwelling urethral catheter
Correct Answer: D Rationale: LPNs who are reassigned to work on a different unit should be assigned to clients who are stable. The older adult diagnosed with cystitis is the most stable and the outcomes for care are fairly predictable. The other clients have more complex problems, as well as a higher risk for instability. LPNs should not accept an assignment that is beyond their knowledge or skills.
The nurse hears a health care provider (HCP) loudly criticizing one of the unlicensed assistive persons (UAP) within the earshot of others. The UAP does not react or respond to the HCP's complaints. What is the best action by the nurse? A. Complete an incident report describing the HCP's unprofessional behavior. B. Encourage the UAP to directly confront the HCP about the unprofessional behavior. C. Walk up to the HCP and quietly state, "This unacceptable behavior has to stop." D. Notify the chief of the medical staff about the HCP's breach of professional conduct.
Correct Answer: B Rationale: The QSEN competency Teamwork and Collaboration requires the nurse to function effectively within nursing, working with inter-professional teams, and fostering open communication and mutual respect. The nurse should first approach the HCP to stop the behavior and then attempt to discuss communication styles that diminish the risks associated with authority gradients among team members. Notifying the chief of the medical staff might be necessary in the future if the HCP continues to act unprofessionally toward the staff. Directly confronting the HCP would most likely cause the HCP to become defensive and should be avoided. Completing an incident report is not necessary at this time.
A client who recently experienced a stroke has an order to ambulate with assistance. Which statement by the nurse provides the best instructions to the unlicensed assistive person (UAP) who will assist the client to ambulate? A. "Stand on the client's strong side when you assist the client to the bathroom." B. "Have the client lift and move the walker out to arm's length, then walk into the walker." C. "As you assist the client to the chair, let me know if the client uses the quad cane correctly." D. "If the client becomes dizzy while walking, ask the client to stop and take 10 fast, deep breaths."
Correct Answer: B Rationale: The nurse should give clear and concise information to the UAP about what is expected to safely complete any task, which is why the option about using the walker is correct. The person assisting the client to ambulate should walk on the client's weak, not strong, side. The nurse should not instruct the UAP to assess or evaluate a client (e.g., "let me know if the client uses the quad cane correctly"). Only nurses can perform those steps of the nursing process. If the client feels dizzy, the UAP should assist them to sit (or ease the client to the floor if they begin to fall.)
A client's family member calls for an update on the client's condition. What should the nurse do first before providing information to the caller? A. Ask the family member who is currently visiting the client if it is okay to release the information. B. Check with the client and obtain permission to provide the caller with the requested information. C. Call the physician to verify the client's condition before updating the caller. D. Decline the caller's request and notify the nurse supervisor of a potential HIPAA violation.
Correct Answer: B Rationale: The nurse must have permission from the client to release information to the caller. If the client is unable to give permission and has a power of attorney for health care (POAH), then information shall only be given to the POAH. Family members can obtain updates from that person. Remember, it is difficult to know who is calling over the phone. The nurse should also be familiar with the organization's policy on requests for information over the phone.
The new graduate nurse understands that patient-centered care, according to QSEN should include which of the following nursing actions? (Select all that apply.) A. Adhering to Institutional Review Board (IRB) guidelines. B. Communicating what care was provided and is needed at each transition in care. C. Participating in designing systems that support effective teamwork. D. Recognizing the boundaries of therapeutic relationships. E. Respecting and encouraging individual expression of client values.
Correct Answer: B,D,E Rationale: The QSEN project defines the knowledge, skills and attitudes for six key areas or required competencies for new nurses. Designing systems that support effective teamwork fits under the Teamwork and Collaboration category. Adherence to IRB guidelines is found under the Evidence-based Practice (EBP) competency.
A client diagnosed with schizophrenia insists that the nurse explain the use and side effects of the medications prescribed for the client. What should the nurse understand before responding to the client? A. The psychiatrist will need to grant permission to discuss the client's medications. B. It is too dangerous for clients who are diagnosed with schizophrenia to know about their medications. C. All clients have a right to be informed about their prescribed medications D. A decision to reinforce or not reinforce information about medications should be made by the nurse alone.
Correct Answer: C Rationale: Clients have the right to be informed about the use and side effects of their medications, regardless of their diagnosis. Clients have the right to refuse treatment, including taking prescribed medications, even if the client has a psychiatric diagnosis such as schizophrenia.
The nurse is reviewing information about the health care organization's efforts to improve quality of care. Which of these statements best describes the goal of continuous quality improvement (CQI) in a health care setting? A. Create a flow chart of department or staff interactions. B. Conduct chart audits for common error discovery. C. Improve the quality of care in a proactive manner. D. Perform actions based on reactive problem solving.
Correct Answer: C Rationale: Continuous quality improvement (CQI) is used to identify ways to correctly do the right thing at the right time. It involves proactive problem-solving. Proactive means implementing steps to prevent something from happening rather than responding to it after it has happened (being reactive). The overall goal of CQI is to improve the quality and safety of health care services.
The nurse has been assigned to four clients. Which client should the nurse see first? A. The client diagnosed with hypertension whose last recorded blood pressure (BP) was 180/90 after returning from the radiology department B. The client with a history of heart failure (HF) who reports going to the bathroom "too much" after taking a diuretic C. The client with a history of coronary artery disease (CAD) reporting dyspnea, nausea and unusual discomfort in the upper back D. The client diagnosed with peripheral artery disease (PAD) who reports cramp-like pains in both calf muscles following physical therapy
Correct Answer: C Rationale: Dyspnea, nausea and unusual discomfort in the upper back can suggest an acute myocardial infarction (AMI) and therefore this client should be seen first. The client with the elevated BP should be seen next. Increased urinary output is an expected finding after taking a diuretic and intermittent claudication is a common and expected finding in PAD.
A client diagnosed with bipolar disorder has been referred to social services for possible placement in a community halfway house after discharge. The social worker telephones the nurse and asks for information about the client's mental status and adjustment. What should the nurse do next to respond to this request? A. Refer the social worker to the health care provider to obtain the requested information. B. Inform the caller that this kind of information is never given over the telephone. C. Verify that the client's medical record includes the client's written consent to release information. D. Go ahead and provide the information, since the client is ready for discharge.
Correct Answer: C Rationale: HIPAA guidelines are very strict about who has access to and can relay information. In order to release written, verbal or electronic information about a client the medical record must include a signed consent form (unless the client is a threat of harm to themselves or others). In addition, a written request for information is commonly asked for prior to the release of any client information. The nurse must also establish proof of the caller's identity before releasing information over the phone. The nurse can accomplish this by asking the social worker for a phone number, then hanging up and returning the call. This allows the nurse to verify the caller's legitimacy before providing the requested information.
During the management of a client's pain, the nurse should adhere to the code of ethics for nurses. Which of these actions should the nurse consider first when treating the client's pain? A. Nurses should not judge a client's pain based on the nurse's values. B. Cultural sensitivity is fundamental to client-centered pain management. C. The client's self-report of pain is the most important consideration. D. Clients have the right to have their pain managed promptly.
Correct Answer: C Rationale: Pain is a complex phenomenon that is perceived differently by each individual. A client's self-reported pain serves as the foundation for the nurse's approach to pain management. The nurse shall keep in mind that pain is subjective and accept the client's report of pain in a nonjudgmental and objective manner. Client-centered and ethical nursing care requires that the nurse recognizes their personally held values and beliefs about the management of pain and that the client's expectations, values and beliefs influence outcomes in the management of their pain.
A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law? A. Clinical specialty certification by an accredited organization B. Above-average performance reviews prepared by nurse manager C. Complete and accurate documentation of assessments and interventions D. Sworn statement that health care provider orders were followed
Correct Answer: C Rationale: The medical record is a legal document. Documentation should include all steps of the nursing process; it must be complete, accurate, concise and in chronological order. Inaccurate or incomplete documentation will raise red flags and may indicate the nurse failed to meet the standards of care. The attorney will review the medical record with the nurse before giving a deposition (sworn pretrial testimony). Above-average performance reviews could be considered supporting information. Certification is an "extra" based on the nurse's initiative; it is, however, unrelated to accurate charting.
Where can the nurse find the most reliable guidelines regarding the appropriate delegation of tasks to unlicensed assistive personnel (UAP)? A. The National Council of State Boards of Nursing (NCSBN). B. The American Nurses Association (ANA) C. That state's nurse practice act (NPA). D. The American Nurses Credentialing Center (ANCC).
Correct Answer: C Rationale: When questions arise regarding who can delegate what activities to which unlicensed provider groups, it is the nurse practice acts (NPAs) of individual states that establish the legal definitions of appropriate delegation practices. Because regulations differ among states, each nurse must identify and understand the regulations for the state in which they practice.
During a discussion about a living will, the client's son states, "I do not understand the need for a living will." What is the best response by the nurse? A. "A designated family member can make all decisions." B. "Do not resuscitate (DNR) orders are automatic under these conditions." C. "Specific instructions are listed for specific diseases." D. "Health care decisions can be made based on the client's wishes."
Correct Answer: D Rationale: Health wishes are written in a legal document such as a living will or advanced directives. These wishes are obtained when clients are medically and cognitively able to do so. Such instructions are to be followed if clients are no longer able to make decisions because of cognitive impairment or unconsciousness. One incorrect response defines a health care surrogate or a durable power of attorney. Another incorrect response defines medical directives and not part of a living will. The final incorrect response is associated with the DNR, which may be predetermined by the client as written in a legal document.
The home health nurse is visiting a client diagnosed with type 1 diabetes and osteoarthritis. The client has difficulty holding and using the prescribed insulin pen. The nurse should refer the client to which community resource person? A. Pharmacist B. Physical Therapist C. Speech Therapist D. Occupational Therapist
Correct Answer: D Rationale: Holding and using an insulin pen requires fine motor skills and good vision. A client with osteoarthritis (OA) might experience limited movement and pain in the joints of the fingers and hand. An occupational therapist can help a client improve the fine motor skills needed to prepare an insulin injection. An occupational therapist works with clients to perform tasks that are needed for smaller movements to maintain activities of daily living or for work. A physical therapist works with general movement problems, mobility stability, range of motion and/or strength training exercises. It would not be appropriate to refer the client to chiropractor and a pharmacist in this situation.
The licensed practical nurse (LPN) is caring for a client with an order that reads, "morphine sulfate 2 mg IV push every 3 to 4 hours as needed for pain." There are no other licensed persons working that shift. Which action should the nurse take? A. Administer the prescribed dose as ordered. B. Give the medication orally and follow-up with the health care provider. C. Check with the pharmacist to verify the order. D. Hold the medication and contact the health care provider.
Correct Answer: D Rationale: LPN/VNs cannot administer medications using intravenous push or bolus route. The nurse will need to contact the health care provider and ask to have the order changed so the medication can be administered by another route.
When walking past a client's room, the nurse hears an unlicensed assistive person (UAP) talking to another UAP. Which of these statements requires further intervention by the nurse? A. "If we work together we can get all of the client care completed." B. "This client seems confused, we need to watch the client closely." C. "I'll come back and make the bed after I go to the lab." D. "Since I am late for lunch, would you perform my client's blood glucose test?"
Correct Answer: D Rationale: Only registered nurses (RNs) and licensed practical or vocational nurses (LPN/VNs) can assign tasks and activities. UAPs cannot re-assign tasks or activities to other UAPs. Nurses are accountable for all nursing care; if UAPs cannot complete assignments, they should notify the nurse, who will reassign the task.
The nurse is handing-off the care of a client admitted with pneumonia to the nurse for the next shift. What client information should the nurse include in the hand-off report, using the S.B.A.R. method? A. Admitting diagnosis, vital signs, room number and insurance information B. Pain, oxygen requirements, insurance information and vital signs C. Marital status, vital signs, religious affiliation and admitting diagnosis D. IV access, admitting diagnosis, allergies and antibiotics given
Correct Answer: D Rationale: S.B.A.R. stands for situation, background, assessment and recommendation. Situation in the model refers to the client's main problem. Background refers to the client's basic information, such as admitting diagnosis, allergies, etc. Assessment refers to objective and subjective data the nurse collects that helps to define the client's problem. Recommendation is the nurse's suggested solution(s) to the problem. Insurance information, marital status and religious affiliation are not shared when using the S.B.A.R. model of communication.
A client is being prepped for a surgical procedure and the nurse is reviewing the consent form with the client. The client asks, "Is there any other way to take care of this without having surgery?" What should the nurse do next? A. Reassure the client that the surgery is the best treatment option. B. Notify the operating room and cancel the surgery. C. Tell the client if they don't want the surgery, they don't have to have it. D. Notify the surgeon that the client has additional questions about the surgery.
Correct Answer: D Rationale: The client should only sign the consent form after all their questions are answered. Notify the appropriate health care provider if the client needs additional information about the surgery. Once the client has all the necessary information, they can then decide not to sign the informed consent form and the surgery can be cancelled. Offering false reassurance violates the client's right to autonomy. Cancelling the surgery is premature at this time.
A newly licensed nurse is concerned about time management. Which action should be most effective in the initial development of a time management plan? A. Ask for additional assistance when necessary to complete tasks B. Set daily goals with the establishment of priorities C. Complete each task before beginning another activity D. Keep a time log for what was done during the hours worked
Correct Answer: D Rationale: The first step in planning for time management is to establish what tasks were done and when they were completed. This provides a baseline for needed changes in any activities and time use log. The key words in this question are "time management," "most effective," and "initial development." Remember the first step in the nursing process is data collection - this applies to both caring for clients and developing management skills.
The nurse is caring for a group of clients when a fire alarm sounds in the hospital cafeteria. What should the nurse do next? A. Find the fire extinguisher. B. Remove oxygen devices. C. Begin evacuating the clients. D. Close all doors in the area.
Correct Answer: D Rationale: The nurse should act immediately to protect the clients under their care. This begins with closing all doors to prevent the fire from spreading. It is not necessary to evacuate the clients because they are not in immediate danger. The fire extinguisher is not needed since there is no active fire in this area. Removing oxygen devices is not required.
The client is admitted with a diagnosis of hyperglycemia and poor glycemic control. Which task can the nurse assign to an unlicensed assistive person (UAP)? A. Reinforce findings of hypoglycemia when the client asks B. Check sensation in the extremities C. Observe for mental status changes every four hours D. Measure blood pressure, pulse and respirations
Correct Answer: D Rationale: UAP can perform standard tasks with predictable outcomes, such as measuring vital signs. They are trained to assist the client with activities of daily living. UAPs cannot assess, plan, teach or evaluate clients.
Which of these activities can the nurse assign to an unlicensed assistive person (UAP)? A. Care for a stable client. B. Reinforce teaching to the client. C. Create a plan of care for the client. D. Provide basic care to the client.
Correct Answer: D (Provide basic care to the client) Rationale: UAPs' limited scope includes (but may not be limited to) assisting with ADLs such as bathing, feeding, toileting, obtaining vital signs, input and output (I/O), performing point of care (POC) tests, such as a blood sugar check or 12-lead electrocardiogram, and recording height and weight. UAPs cannot reinforce teaching, create a plan of care or assume nursing care for a client - even if the client is stable.
The nurse is providing care for a client who was recently diagnosed with end-stage heart failure. The client does not have advance directives in place. Which of the following statements by the nurse would be appropriate? (Select all that apply.) A. "What does your family know about your condition and prognosis?" B. "Have you thought about what you want done as your disease progresses?" C. "Someone in your family needs to learn how to do cardiopulmonary resuscitation (CPR)." D. "Have you thought about your options for a heart transplant?" E. "Have you discussed your wishes regarding resuscitation with your health care provider?"
Correct Answers: A, B, E Rationale: Approximately half of all deaths from heart failure are sudden and without warning. It is important to assist the client and family in planning for the possibility of sudden cardiac death at home. The nurse should discuss advance directives with the family and encourage them to develop a plan of action that addresses the client wishes. Although heart transplants are an option for clients with heart failure, discussions about treatment options (including a transplant) are the responsibility of the health care provider, not the nurse. Asking the client about their current understanding of the disease will help the nurse determine what additional education might be needed. Although it might be helpful for family members to know how to perform CPR, it is not appropriate for the nurse to request CPR certification.
The nurse is preparing to administer regular insulin subcutaneously to a client at 0800. What information from the client's electronic health record should the nurse review in order to safely administer the medication? (Select all that apply.) A. 0600 daily weight. B. Name and date of birth. C. Medication administration record (MAR). D. 0800 vital signs. E. 0700 blood glucose.
Correct Answers: B,C,E Rationale: The nurse must review the appropriate information in order to safely administer medications. The use of two client identifiers is to ensure the identity of the correct client. The nurse must review the medication administration record (MAR) to verify the correct medication, dose, and time. The nurse should review the client's most recent blood sugar value before administering the insulin to prevent hypoglycemia.
