NURS 1240 Collaboration EAQ
Which statement by an unlicensed assistive personnel (UAP) who is assisting the nurse in caring for a group of clients indicates a correct understanding of the UP's role? - "I will turn off clients' intravenous lines that have infiltrated." - "I will take clients' vital signs after their procedures are over. - "I will use unit written materials to teach clients before surgery." - "I will help by giving medications to dients who are slow in taking pills."
"I will take clients' vital signs after their procedures are over. rationale: Monitoring vital signs after procedures is within the scope of a UP's role. Registered professional nurses or licensed practical nurses, not UPs, evaluate for intravenous fluid infiltration. Client teaching is performed by registered nurses or licensed practical nurses, not UPs. Medication administration is performed by registered nurses or licensed practical nurses, not UPs
When admitting an older client, the stool specimen confirmed a diagnosis of a methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse inquires about potentially assigning Room 2010, Bed B, the same isolation room as another client (2010, Bed A) who has MRSA. Which response would the nurse receive? - "The other client's infection is not contagious." - 'This is the usual practice when antibiotic therapy is started." - "Placing clients with the same infection in 1 room is safe." - "As soon as a private room becomes available, we will move the client."
"Placing clients with the same infection in 1 room is safe." rationale: There is no need to separate 1 client with MRSA from another client with the same infection. MRSA infections are highly contagious. MRSA infections are resistant to most antibiotics, especially methicillin. Clients with the same infection can remain in the same room; contact precautions are necessary to protect visitors and staff members.
Which of these clients can be provided care safely by unlicensed assistive personnel (UP)? Select all that apply. - A client with severe pain - A client who is extremely upset - A client who is stable - A client who is recovering - A client with suicidal intentions
A client who is stable; A client who is recovering rationale: The greater the stability of a client, the more likely it is that UAP can provide safe client care. It is also easy for a UP to care for a client who is recovering. A client with severe pain is anxious and agitated, and requires more care than a UP can provide. Client care may be affected when the client is extremely psychologically upset and has suicidal intentions, both of which require more intensive care.
Which organization provides scope and practice guidelines on the roles and responsibilities for nursing and nursing specialties? - State Nursing Association - National League of Nursing - American Nurses Association - Academy of Medical Surgical Nurses
American Nurses Association rationale: The American Nurses Association develops and publishes scope and standards of practice guidelines for nursing and nursing specialties. Many professional organizations have state-level nursing associations, but they do not publish standards and scope of practice. The National League of Nursing is a professional organization related to the education of nurses. The Academy of Medical Surgical Nurses publishes scope and standards of practice for general medical surgical nursing, but not nursing and nursing specialties
Which component of delegation is the ability to perform duties in a specific role? - Authority - Responsibility - Accountability - Legal authority
Authority rationale: Authority is the ability to perform duties in a specific role. Responsibility refers to reliability, dependability, and obligation to accomplish work. Accountability determines whether a person's actions are appropriate and provides a detailed explanation of what occurred. Legal authority is the ability to transfer selected nursing activities in a given situation to a competent individual.
Which concept refers to the ability to perform duties in a specific role? - Authority - Responsibility - Accountability - Legal authority
Authority rationale: Authority is the ability to perform duties in a specific role. Responsibility refers to reliability, dependability, and obligation to accomplish work. Accountability determines whether a person's actions were appropriate and provides a detailed explanation of what occurred. Legal authority is the ability to transfer selected nursing activities in a given situation to a competent individual.
Which health care team member acts as a delegator in the absence of the registered nurse (RN)? - Charge nurse - Patient care associate - Licensed practical nurse (LPN) - Unlicensed assistive personnel (UAP)
Charge nurse rationale: The charge nurse acts as a delegator based on knowledge and experience in clinical settings. In the absence of an RN, the charge nurse usually delegates the tasks. A patient care associate assists and monitors vital signs. LPNs and UPs are considered delegates due to insufficient experience and training.
Which health care team member is familiar with all the needs of any individual client? - Orderly - Social worker - Charge nurse - Unlicensed assistive personnel (UAP)
Charge nurse rationale: The charge nurse is involved in the coordination and assignment of care to individual clients. The charge nurse is the only person familiar with all the needs of any individual client under care. Orderlies are unlicensed assistive personnel delegated to care for the client's basic needs, and they do not have complete knowledge of a client's condition. A social worker is not familiar with all the needs; their focus is on social/emotional support, financial needs, and community resources for the client and family. The UAP is involved in basic care of the client.
Which employee would be competent in critical thinking, leadership, communication, and time management skills? Select all that apply. - Charge nurse - Student nurse - Registered nurse (RN) - Unlicensed assistive personnel - Licensed practical nurse (LPN)
Charge nurse; Registered nurse (RN) rationale: The charge nurse and RN would each have a sophisticated level of competency in critical thinking, leadership, communication, time management, clinical practice, and organizational skills. These skills are. helpful for the charge nurse or the RN when serving as a delegator. The student nurse, unlicensed assistive personnel, and LPN do not delegate because they are less skilled than the charge nurse is.
Which member of the health care team has the primary responsibility for the success of the therapy and rehabilitation according to Alcoholics Anonymous? - Nurse - Client - Counselor - Psychiatrist
Client rationale: According to the philosophy of Alcoholics Anonymous, the client who has problems with alcohol must identify their own need to seek help and become the primary rehabilitator. The nurse gives support. The counselor gives direction. The psychiatrist prescribes treatments.
Which client's plan of care cannot be delegated? A: Changing the client's position B: Assisting the client in walking C: Teaching care measures for a diabetic client D: Helping the client while bathing
Client C rationale: Teaching care measures for a diabetic client (client C) is complex and multifaceted; therefore it cannot be delegated. Changing the client's position, assisting the client in walking, and helping the client while bathing are simple and can be delegated to unlicensed assistive personnel (UAP).
Which factor would the nurse consider when setting priorities for care during a shift? Select all that apply. - Client acuity - Unit organization - Availability of resources - Own experience and expertise - Philosophies and models of care
Client acuity; Unit organization; Availability of resources; Own experience and expertise; Philosophies and models of care rationale: When setting priorities for care, the nurse must consider client acuity, organization of the unit, assessment of available resources, recognition of own experience and expertise, and an understanding of care philosophies and models of care used on the unit
Which information, obtained during a client's health history, would the nurse classify as biographical information? Select all that apply - Symptoms - Client's age - Family structure - Type of insurance - Occupation status
Client's age; Type of insurance; Occupation status rationale: Biographical information is factual demographic data about the client usually obtained by the admitting office staff. The client's age, types of insurance, and occupation status are considered biographical information. If the client presents with an illness, the nurse gathers details about the symptoms of the illness, which is descriptive information, not biographical information. The nurse obtains information about family structure while assessing the family history of the client. It is not biographical information.
Which statement is true about the disaster triage tag system? - Yellow tags are given to 'walking-wounded clients." - Clients who are in shock are given a black tag. - Clients with airway obstruction, who require immediate attention, are given a red tag. - Green tags are given to clients who require treatment within 30 minutes to 2 hours of admission.
Clients with airway obstruction, who require immediate attention, are given a red tag. rationale: Red tags are given to clients with conditions such as airway obstruction and shock, who have immediate threats to life and should be treated immediately. Shock is a condition requiring immediate care and therefore should be given a red, not black, tag. "Walking-wounded clients" are given a green tag. Clients who are not expected to live or are dead are given a black tag. Clients who sustained major injuries and need to be treated in 30 minutes to 2 hours should be given a yellow tag.
Which element is the critical factor among health care professionals, state agencies, and federal agencies to determine when and how to evacuate safely during a natural disaster? - Cooperation - Classification - Collaboration - Communication
Communication rationale: Communication is the critical factor among health care professionals, state agencies, and federal agencies to determine when and how to evacuate safely during a natural disaster. Cooperation, classification, and collaboration, although important, are not the critical factors to determine when and how to safely evacuate during a natural disaster.
The objective of a therapy group is to assist the members to change behavior so they are able to participate in life in a more satisfying manner. Which leadership style is best to achieve this objective? - Democratic, guiding - Hierarchical, directing - Autocratic, controlling - Laissez-faire, observing
Democratic, guiding rationale: A democratic, guiding leader assists the group to develop its maximum potential by facilitating and balancing group forces. Under this style, group members are encouraged to take responsibility for personal and group outcomes. A hierarchical, directing leader or an autocratic, controlling leader makes most of the decisions and controls the group. Under these styles, the members have less responsibility for making behavioral changes. A laissez-faire, observing leader allows group members to take over the group. Under this style, the group members might learn how to make behavioral changes, but the outcome is less predictable, because the leader has no input.
Which emergency medical service agency offers service for a group of clients admitted to the emergency unit with mass fatalities? - Medical Reserve Corps (MRC) - Hospital Incident Command System (HICS) - International Medical-Surgical Response Teams (IMSRT) - Disaster Mortuary Operational Response Teams (DMORT)
Disaster Mortuary Operational Response Teams (DMORT) rationale: The National Disaster Medical System (NDMS) is responsible for managing the Federal Government's medical response to medical emergencies and disasters. One of their additional services is the DMORT. DMORTS manage mass fatalities. The MRC offers its services to health care facilities or the community in a supportive to supplemental capacity during times of need, such as a disaster or pandemic disease outbreak. HICS is a part of National Incident Management System (NIMS) that standardizes disaster operations. IMSRT establishes fully functional field surgical facilities.
Which three strategies can the nurse perform while assisting other nurses in making delegation decisions? Select all that apply. - Doing - Telling - Asking - Offering - Participating
Doing; Asking; Offering rationale: The nurse can assist other registered nurses with delegation decisions by using three strategies: asking, offering, and doing. Telling and participating are the strategies used by the nurse to communicate with the delegatee.
Which safety precaution would the nurse employ when assisting with the removal of a client's vaginal radium seeds? - Clean the radium in ether or alcohol. - Wear foil-lined rubber gloves while handling the radium. - Ensure long forceps are available for removing the radium. - Document how long the radium seeds were in the vaginal vault.
Ensure long forceps are available for removing the radium. rationale: Radium must be handled with long forceps because distance helps limit exposure. The nurse does not clean radium implants. Foil-lined rubber gloves do not provide adequate shielding from the gamma rays emitted by radium. The amount and duration of exposure are important in assessing the effect on the client; however, documentation will not affect safety during removal.
Which assessment finding of a client being treated in the emergency department after a motor vehicle collision indicates the need for immediate health care provider intervention? Select all that apply. - Facial edema - Septal deviation - Clear nasal drainage - Oxygen saturation 89% - Bilateral periorbital bruising
Facial edema; Septal deviation; Clear nasal drainage; Oxygen saturation 89%; Bilateral periorbital bruising rationale: Facial edema and septal deviation indicate that the client has sustained facial injuries. Clear nasal drainage is an indication of a cerebrospinal fluid leak, and the nurse would immediately report the finding and send the drainage to be tested for glucose. An oxygen level of 89% would be reported to the health care provider as it could indicate nonvisible injuries. "Raccoon eyes" or bilateral periorbital bruising indicates a basilar skull fracture and requires immediate medical treatment.
Which primary purpose does the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) serve? - Facilitates communication between researchers and clinicians - Aids in teaching psychopathology to mental health professionals - Increases accuracy in public health statistics through use of diagnostic codes - Facilitates classification of mental disorders and guides the determination of diagnosis
Facilitates classification of mental disorders and guides the determination of diagnosis rationale: The primary purpose of the DSM-5 is to guide the clinician in identifying a client's mental health or psychiatric diagnosis. Although the DSM-5 is useful in facilitating communication and research, teaching psychopathology, and improving public health statistics, these are secondary uses for this publication.
Which step in the nursing process would involve promoting a safe environment for the client? - Planning - Diagnosis - Assessment - Implementation
Implementation rationale: The nurse promotes a safe environment during the implementation stage of the nursing process. During the planning stage, the nurse develops an individualized care plan for the client. The plan contains strategies and alternatives to achieve specific outcomes. During the diagnosis stage, the nurse analyzes the assessment data to determine the health care issues. The nurse collects comprehensive data pertinent to the client's health and situation during the assessment stage.
Which factor is the likely cause of the laboratory result when arterial blood gases done on a client who is being resuscitated after cardiac arrest show a low pH? - Ketoacidosis - Irregular heartbeat - Lactic acid production - Sodium bicarbonate administration
Lactic acid production rationale: Cardiac arrest causes decreased tissue perfusion, which results in anaerobic metabolism and lactic acid production. Fat-forming ketoacids occur in diabetes. An irregular heartbeat does not cause acidosis. Sodium bicarbonate causes alkalosis, not acidosis.
Which health care team member would the nurse expect could be delegated with the task of administering oral medication to a client per the functional model? - Registered nurse (RN) - Patient care associate - Licensed practical nurse (LPN) - Unlicensed assistive personnel (UAP)
Licensed practical nurse (LPN) rationale: The LP can give oral medication to a client. The RN gives intravenous (IV) medication to a client. Patient care associates assist and monitor vital signs. UP perform all hygienic tasks.
A client who sustained a leg fracture is prescribed intramuscular analgesic medication. Which health care professional can be safely delegated this task? - Registered nurse (RN) - Chief nursing officer - Licensed practical nurse (LPN) - Unlicensed assistive personnel (UAP)
Licensed practical nurse (LPN) rationale: The LPN is authorized to administer oral and intramuscular medications. An RN is a delegator who can administer intravenous medications. The chief nursing officer does not usually provide direct client cake. UAPs can perform tasks such as positioning the client and maintaining the hygiene of the client.
Which type of relationship between the nurse delegator and delegate causes the nurse delegator to use the leadership behavior of "telling?" - Limited - Established - New or developing - Developing or ongoing
Limited rationale: When the delegator and delegate are unlikely to work together again, the relationship is limited and the delegator uses the leadership behavior of "telling." When the relationship between delegator and delegate is established, the delegator uses the leadership behavior of "delegating." When the relationship between delegator and delegate is new or developing, the delegator uses the leadership behavior of "participating." When the relationship between delegator and delegate is developing or ongoing, the delegator uses the leadership behavior of "selling."
Which health care personnel working at an emergency operation center (EOC) is responsible for calling the infectious disease health care provider during a mass casualty swine flu outbreak if the need is identified? - Triage officer - Public information officer - Medical command physician - Hospital incident commander
Medical command physician rationale: Medical command physician in the EOC is responsible for identifying the need for and calling in specialty providers such as an infectious disease health care provider. The triage officer evaluates each client to determine priorities for treatment. The public information officer serves as a liaison between the health care facility and the media. The hospital incident commander assumes leadership for implementing the institutional plan.
Which personnel are responsible for identifying the need for and calling in specialty trained providers in emergencies? - Triage officer - Public information officer - Medical command physician - Hospital incident commander
Medical command physician rationale: The medical command physician is responsible for identifying the resource needs of the clients. The medical command physician identifies the need for and calls in the specialty trained providers in emergencies. Triage officers are responsible for rapidly evaluating each client to determine priorities for treatment. The public information officer serves as a liaison between the health care facility and the media. The hospital incident commander is the one who assumes overall leadership for implementing the emergency plan.
Which role would the unlicensed assistive personnel (UAP) have when caring for a client receiving intravenous (IV) therapy? - Monitoring clinical manifestations - Collecting the data to be used in the assessment of the IV site - Administering IV fluids and medications - Evaluating the client for clinical manifestations
Monitoring clinical manifestations rationale: In IV therapy the role of the registered nurse (RN) is to collect the data that can be used in the assessment of the IV site. Monitoring clinical manifestations is performed by the unlicensed assistive personnel and the data are reported to the RN. Administering IV fluids and medications is done by an RN or licensed practical nurse (LP). Evaluating the client for clinical manifestations is performed by the RN.
Which health care team member is the designated delegator? - Unit secretary - Nurse manager - Registered nurse (RN) - Licensed practical nurse (LPN)
Nurse manager rationale: The nurse manager is the designated delegator. The unit secretary has no formal medical preparation or legal recognition. The RN is answerable to the delegator. The LP has a dependent status, functioning under the direction of a RN.
Which behavior of the nurse leader is characterized as "delegating" according to Hersey's model? - Guiding or directing - Observing or monitoring - Explaining or persuading - Encouraging or problem-solving
Observing or monitoring rationale: Observing or monitoring behavior of the leader is characterized as delegating" according to Hersey's model. Guiding or directing behavior of the leader is characterized as "telling according to Hersey's model. Explaining or persuading behavior of the leader is characterized as selling" according to Hersey's model. Encouraging or problem-solving behavior of the leader is characterized as "participating" according to Hersey's model.
Which task can the registered nurse (RN) safely delegate to the unlicensed assistive personnel (UAP) while caring for a client with gastrosophageal reflex disease? - Positioning the bed - Evaluating the vitals - Tube feeding the client - Determining calorie needs
Positioning the bed rationale: The UAP should be assigned tasks that are simple and do not involve any complications. Positioning the bed at 30 degrees or more is one of the essential tasks that can be assigned to the UP under supervision. Evaluating vitals is the duty of the registered nurse. Tube feeding the client is a very sensitive procedure that can be done by an RN or a trained licensed practical nurse (LP). Determining the calorie needs of the client is the job of a dietician.
Which laboratory result is important to communicate quickly to the health care provider? - Blood glucose 98 mg/dL (5.44 mmol/L) - Hemoglobin 14.1 g/dL (141 mmol/L) - Potassium 3.0 mEq/L (3.0 mol/L) - White blood cell 9200/mm 3 (9.2 × 10 °/L)
Potassium 3.0 mEq/L (3.0 mol/L) rationale: A potassium level of 3.0 mEg/L (3.0 mmol L) is indicative of hypokalemia, which needs to be quickly communicated to the provider so that potassium supplementation can be started. Normal values for an adult are 3.5 to 5.0 m Eq/L (3.5-5.0 mmol/L). The blood glucose level is within the normal range of 70 to 100 mg/dL (3.89-5.55 mmol/L). Hemoglobin of 14.1 (141 mol/L) is within normal values. White blood cell level of 9200 cells/mm 3 is within the normal range of 4000 to 11,000 cells/mm 3 (4 to 11 × 10 9/L).
A group of bomb blast victims needs to be transported to the hospital immediately. Which staff members of an emergency unit are most appropriate to handle this situation? - Triage officer - Medical command physician - Prehospital care providers - Emergency medicine physician
Prehospital care providers rationale: Prehospital care providers are the first caregivers who provide transport to the emergency department by ambulance or helicopter for clients in an emergency situation. Triage officers are responsible for evaluating each client to determine priorities for treatment. The medical command physician decides the number, acuity, and resource needs of clients. Emergency medicine health care providers have specialized education and training in emergency client management.
Which duty would the nurse as delegator have if the delegate has limited knowledge and ability to perform a task? - Provide guidance. - Observe and motivate. - Explain what is to be done. - Establish mutual expectations.
Provide guidance. rationale: If the delegate has limited knowledge and ability to perform a task, the delegator would provide guidance. The delegator is expected to observe and monitor the task performed by the delegate to ensure that the delegate has the ability and willingness to establish a relationship and accomplish work. The registered nurse explains the task and how to execute it if the situation involves a new task and the relationship is ongoing. If the delegate is new to the workplace but has the ability and willingness to perform a task, the delegator would establish mutual expectations and conditions of performance in order to establish a good relationship.
Which statement reflects a pairing approach to delegation of registered nurse (RN) and unlicensed assistive personnel (UAP) assignments? - UAP serves the unit and has minimal RN direction. - RN and UP are consistently scheduled to work together. - UAP works from a task list as outlined in the job description. - RN and UAP only provide care together for a given set of clients during a given shift.
RN and UAP only provide care together for a given set of clients during a given shift. rationale: A pairing approach involves the RN and UP working together only during a given shift, they are not intentionally scheduled together consistently. In a unit-based scenario, UP serve the unit overall and interact minimally with the RN. Assignment of a RN and UP to the same schedule reflects a partnering approach. Having UPs work from a specific task list as outlined in the job description is characteristic of a unit-based approach.
Which activity would the nurse manager complete during an emergency event when acting as the triage officer according to the Hospital Incident Command System (HICS)? - Facilitating client movement through the system - Bringing in personnel and supply resources to meet needs - Rapidly evaluating each person who comes to the hospital - Identifying the need for and call in specialty providers
Rapidly evaluating each person who comes to the hospital rationale: In the role of triage officer, the nurse would rapidly evaluate each person who comes to the hospital, including those triaged in the field. The hospital incident commander facilitates client movement through the system and brings in personnel and resources to meet needs. The medical command physician identifies the need for and calls in needed specialty providers.
Which topic addressed by a new nurse when talking with a client who has neurocognitive disorder due to Lewy bodies would cause the charge nurse to follow-up? - Married life - Work years - Recent days - Young adulthood
Recent days rationale: The charge nurse would follow-up if the new nurse talked about recent days. Neurocognitive disorder due to Lewy bodies is characterized with short-term memory loss, unpredictable cognitive shifts, and sleep disturbances. Thus talking about recent days would be ineffective. Memories of remote events (e.g., married life, working years, young adulthood usually remains fairly intact. Therefore the charge nurse would not have to follow-up when the new nurse talked to the client about these topics.
Which health care professional is authorized to delegate work to other health care members? - Registered nurse (RN) - Licensed practical nurse (LPN) - Pharmacy technician - Unlicensed assistive personnel (UAP)
Registered nurse (RN) rationale: Delegating work is the most effective professional management strategy that an RN can implement in clinical practice to improve the safety and quality of client care. RNs can delegate work to LPs and UPs; neither LPs nor UAPs can delegate. A pharmacy technician cannot delegate to nursing personnel.
Which health care team member is most accountable for an initial assessment and the ongoing evaluation of client care? - Client - Registered nurse (RN) - Licensed practical nurse (LPN) - Unlicensed assistive personnel (UAP)
Registered nurse (RN) rationale: RNs are accountable for initial assessment and the ongoing evaluation of client care. The client is not responsible for assessment and evaluation. The LPN has a responsibility to gather data and report client care. UAP perform tasks as delegated by the RN.
Which health care team member is accountable for the ongoing evaluation of a client's care? - Registered nurse (RN) - Chief nursing officer (CO) - Licensed practical nurse (LPIN) - Unlicensed assistive personnel (UAP)
Registered nurse (RN) rationale: RNs are accountable for the initial assessment and the ongoing evaluation of a client's care. CNOs are accountable for establishing systems to communicate competency requirements related to delegation. The LP directly provides care to the client. UPs provide client care under the supervision of an RN.
A group of individuals is working as a team in a rehabilitation program. Which nursing team member has the responsibility for acting as the team leader? - Unit secretary - Registered nurse (RN) - Licensed practical nurse (LPN) - Unlicensed assistive personnel (UAP)
Registered nurse (RN) rationale: The RN has responsibility for a group of individuals who work on a team. The unit secretary is an individual with no medical training and cannot accept any responsibilities of the team. The LP and UP are individuals who work under the directions of a RN.
A client with chronic asthma is being cared for in the inpatient care unit. Which health care team member would be delegated to assess the client on a regular basis? - Charge nurse - Registered nurse (RN) - Unlicensed assistive personnel (UAP) - Licensed practical nurse (LPN)
Registered nurse (RN) rationale: The RN is a licensed nursing professional and is responsible for assessing the asthmatic symptoms of the client and providing care. The charge nurse is responsible for the coordination and assignment of tasks for the client's care. UAPs have a scope of practice that is limited and does not include assessments. The LPN does not assess the client's condition, but is responsible for providing treatment prescribed by the health care provider and delegated by the RN.
A client with an acute exacerbation of asthma has been admitted to the hospital. Which health care team member would be delegated to perform an initial assessment on this client? - Charge nurse - Registered nurse (RN) - Unlicensed assistive personnel (UAP) - Licensed practical nurse (LPN)
Registered nurse (RN) rationale: The RN is a licensed nursing professional and is responsible for assessing the asthmatic symptoms of the client for providing care. The charge nurse is responsible for the coordination and assignment of tasks for the client's care. Unlicensed assistive personnel scope of practice does not include assessment of clients. The licensed practical nurse does not assess the client's condition, but rather is responsible for providing treatment prescribed by the health care provider and delegated by the RN.
Which member of the health care team is responsible for providing supervision to the unlicensed assistive personnel (UAP) providing care for a client? - Charge nurse - Nurse manager - Registered nurse (RN) - Another UAP
Registered nurse (RN) rationale: The RN supervises UPs and also licensed practical nurses (LPs) in providing care to the client. The charge nurse and the nurse manager may supervise RNs. The charge nurse delegates the tasks to the LP and UP when the RN does not delegate. The nursing manager is in charge of the RN, LP, and UAP. Another UAP does not supervise the UP when the RN delegates tasks.
Which health care team member supervises unlicensed assistive personnel (UAPs) in providing care to the client? - Charge nurse - Nurse manager - Registered nurse (RN) - Unlicensed assistive personnel (UAP)
Registered nurse (RN) rationale: The RN supervises UPs and licensed practical nurses (LPs) in providing care to the client. The charge nurse and the nurse manager may supervise RNs. The charge nurse delegates tasks to the LPN and UP when the RN does not. The nursing manager is in charge of the RN, LPN, and UAP. The UAP does not supervise other UAPs.
Which health care professional would the nurse know is held accountable for the tasks performed by the unlicensed assistive personnel (UAP)? - Registered nurse (RN) - Licensed vocational nurse (LVN) - Primary health care provider - Unlicensed nursing practitioner (UNP)
Registered nurse (RN) rationale: The delegator is held accountable for tasks performed by the delegate. In this situation, the delegator is the RN; therefore the RN is held accountable for the tasks performed by the UAP. The RN is also accountable for delegation to LVNs. The primary health care provider and UNP are not held accountable for the UAP.
The client is experiencing postoperative pain and requests a pain shot. Which health care providers are legally permitted to administer an intramuscular (IM) injection to the client? Select all that apply. - Registered nurse (RN) - Licensed practical nurse (LPN) - Licensed vocational nurse (LVN) - Unit secretary - Unlicensed assistive personnel (UAP)
Registered nurse (RN); Licensed practical nurse (LPN); Licensed vocational nurse (LVN) rationale: In this situation, the LPN and LVN can administer the IM medication; the RN can also administer the medication when the condition is severe. The unit secretary is not authorized to give iM medication. The UAP can obtain, record, and report vital signs and provide hygiene care as delegated
Which task is achieved by the delegator when they engage in self-care to enhance their ability to care for the health care team? - Managing - Renewing - Explaining - Motivating
Renewing rationale: Renewing is the task achieved by the delegator when they engage in self-care to enhance their ability to care for the health care team. Managing is achieved when the delegator assists the staff in planning, priority-setting, and decision-making. Explaining occurs when the delegator teaches and interprets information for client well-being. Motivating is achieved when the delegator inspires the staff to fulfill a mission.
Which intervention related to restraint use is appropriate to delegate to unlicensed assistive personnel (UAP)? - Appropriate use of restraints - Determination of the need for restraints - Assessment of the client's behavior - Routine checks of the client while in restraints - Orientation of the client to the environment
Routine checks of the client while in restraints rationale: UAP can perform routine checks of the client in restraints. Determination of appropriate use of restraints and the need for restraints, and the assessment of a client's behavior, are not tasks that can be delegated to UAP.
In a health care organization, which role would a resource person assigned by the nurse manager have? - Delegates tasks - Supervises actions - Serves as a mentor - Reassigns duties to workers
Serves as a mentor rationale: The nurse manager assigns a resource person in a health care organization to serve as a mentor for the agency nurse to prevent potential problems that could arise if the staff member does not know the institutional routine. The nurse manager also delegates a task, supervises actions, and reassigns duties to workers.
Which role does shark cartilage play in the management of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS)? - Shark cartilage enhances immunity. - Shark cartilage reduces oral thrush. - Shark cartilage is a complementary therapy. - Shark cartilage is a nutritional supplement.
Shark cartilage is a complementary therapy. rationale: Shark cartilage is considered an alternative or complementary therapy to prescribed medications for clients with HIV and AIDS. Lymphocyte transfusions and bone marrow transplants are used to improve immunity in clients with HIV and AIDS. Lemon juice and lemongrass may provide relief from oral thrush in some clients with HIV and AIDS. A high-calorie, high-protein diet is advised to clients with HIV and AIDS to improve their nutritional status.
Which motto is the main focus of Hersey's 2006 model? - Information decay - Information salience - Situational leadership - Individual accountability
Situational leadership rationale: Hersey's 2006 model provides a solid foundation for delegation decisions. The main focus of this model is situational leadership. The core competencies of a situational leader are the ability to diagnose the performance, competence, and commitment of others; to be flexible; and to partner for performance. Anthony and Vidal describe characteristics of communication that interfere with the delegation process, such as information decay. They also describe information salience, or the quality, meaning, and clarity of the information. ANA mentioned individual accountability, the expectation of accountability and responsibility in 2011, specifically referencing delegation.
Which member of the interprofessional team is appropriate for the nurse to ask for support in informing and consoling the family of a terminally ill client who has died? - Primary health care provider - Pharmacist - Social worker - Occupational therapist
Social worker rationale: The social worker on the interprofessional team helps the family members prepare for the client's death and during the grief and bereavement process. The nurse involves the social worker in consoling the family members in this situation. The primary health care provider and pharmacist may not be involved in consoling the family members after the client's death, nor may the occupational therapist be involved at this stage.
Which elements are integrated into delegation decisions? Select all that apply. - Stability - Leadership - Clinical practice - Critical thinking - Communication
Stability; Critical thinking rationale: The four elements that foster effective delegation decisions are safety, critical thinking, stability, and time. Leadership, critical thinking, communication, and clinical practice are the competency skills of a charge nurse.
In which situation would the nurse consider family members as the primary source of information? Select all that apply. - The client is an older adult. - The client is an infant or child - The client is brought in as an emergency. - The client is critically ill and disoriented. - The client visits the outpatient department.
The client is an infant or child; The client is brought in as an emergency.; The client is critically ill and disoriented. rationale: The nurse interviews the parents who care for the infant or child. Thus the parents become the primary source of information. A client who is brought to the emergency department may not be in a position to explain the circumstances that led to the visit. In this case the family or significant others who accompany the client become the primary source of information. The family becomes the primary source of information when the client is critically ill, disoriented, and unable to answer questions. Generally, the client is the primary source of information. The older adult who is conscious, alert, and able to answer the nurse's questions is the primary source of information. The client who visits the outpatient department is capable of providing accurate answers to the nurse's questions. This client is the primary source of information during assessment.
Which factor supports task delegation to nursing staff personnel according to the National Council of State Boards of Nursing (NCSBN) Decision Tree? Select all that apply. - The task is within the nurse's scope of practice. - The task may be performed with a predictable outcome. - Agency policies and protocols are available for the task or activity. - The task is performed according to an established sequence of steps. - The staff member has the appropriate knowledge, skills, and abilities required to complete the task.
The task is within the nurse's scope of practice.; The task may be performed with a predictable outcome.; Agency policies and protocols are available for the task or activity.; The task is performed according to an established sequence of steps.; The staff member has the appropriate knowledge, skills, and abilities required to complete the task. rationale: According to the NCSB Decision Tree, for a task to be delegated it must be within the nurse's scope of practice and have a predictable outcome. Agency policies and procedures must be available for the task, and it must have an established sequence of steps. The staff member to whom the task is delegated must have the appropriate knowledge, skills, and abilities to perform the task
Which description by the nurse is a correct explanation of delegation? - The transfer of responsibility for the performance of an activity - The person's responsibility and accountability for individual actions or omissions - The active process of directing, guiding, and influencing the outcome of an individual - The transfer of both the accountability and responsibility from one person to another
The transfer of responsibility for the performance of an activity rationale: Delegation is the transfer of responsibility for the performance of an activity. Personal liability defines each person's responsibility and accountability for individual actions or omissions. Supervision is defined as the active process of directing, guiding, and influencing the outcome of an individual. Assignment is the transfer of both the accountability and the responsibility from one person to another.
Which purposes support the process of delegation? Select all that apply. - To achieve nursing goals - To improve client outcomes - To develop critical judgment skills - To understand the art of delegation - To apply delegation decisions in clinical nursing practice
To achieve nursing goals; To improve client outcomes rationale: The overall purpose of delegation is to achieve nursing goals and improve client outcomes. The delegation process requires decision-making, which involves developing critical judgment skills, understanding the art of delegation, and applying delegation in a clinical nursing practice.
In which situation would a delegator identify that a delegate is unable to perform an assigned task? - When the delegatee is upset - When the delegatee is bored - When the delegate is anxious - When the delegate is knowledge-deficient
When the delegate is knowledge-deficient rationale: A delegate is identified as less able to perform a specific work when there is a knowledge deficit. When the delegate is upset, bored, or anxious, the delegator will identify that the delegate is unwilling to perform a specific task.
