Ch 6

An experienced LPN is working under the supervision of the RN. The LPN is providing nursing care for a patient who has a respiratory problem. Which activities should the RN delegate to the experienced LPN? (Multiple choice) 1. Auscultate breath sounds 2 Administer medications via metered-dose inhaler 3 Complete in-depth admission assessment 4 Initiate the nursing care plan 5 Evaluate the patient's technique for using MDIs

1 Auscultate breath sounds 2 Administer medications via metered-dose inhaler

The nursing assistant tells a nurse that a patient who is receiving oxygen at a flow rate of 6L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should the nurse suggest to improve the patient's comfort for this problem? 1. Suggest that the patient's oxygen be humidified 2. Suggest that simple face mask be used instead of a nasal cannula 3. Suggest that the patient be provided with an extra pillow 4. Suggest that the patient sit up in a chair at the bedside

1. Suggest that the patient's oxygen be humidified

A nurse is caring for a patient who is diagnosed with coronary artery disease and sleep apnea. Which action should the nurse delegate to the NAP? 1. Discuss weight-loss strategies such as diet and exercise with the patient. 2. Teach the patient how to set up the CPAP machine before sleeping 3. Remind the patient to sleep on his side instead of his back 4. Administer modfinil (Provigil) to promote daytime wakefulness

3. Remind the patient to sleep on his side instead of his back

A nurse is assigned to care for the following patients. Which patient should the nurse assess first? 1. 60 y/o pt on a ventilator for whom a sterile sputum specimen must be sent to the lab 2. A 55 y/o with COPD and a pulse ox reading from the previous shift of 90% 3. A 70 y/o with pneumonia who needs to be started on IV antibiotics 4 A 50 y/o with asthma who complains of shortness of breath after using a bronchodilator

4 A 50 y/o with asthma who complains of shortness of breath after using a bronchodilator

A respiratory therapist performs suctioning on a patient with a closed head injury who has a tracheostomy. Afterward, the NAP obtains vital signs. The nurse should communicate that the NAP needs to report which vital sign value or values immediately? (Multiple choice) 1 HR of 96 bpm 2 RR of 24 bpm 3 Pulse ox sat of 95% ' 4 Tympanic temperature of 101.4F (38.6C)

4 Tympanic temperature of 101.4F (38.6C)

An assistant nurse manager is making assignments for the next shift. Which patient should the assistant nurse manager assign to a nurse with 6 months of experience and who has been floated from the surgical unit to the medical unit? 1. A 58-year-old on airborne precautions for tuberculosis (TB) 2. A 68-year-old who just returned from bronchoscopy and biopsy 3. A 69-year-old with COPD who is ventilator dependent 4. A 72-year-old who needs teaching about the use of incentive spirometry

4. A 72-year-old who needs teaching about the use of incentive spirometry

When making assignments for the nursing team, an RN carefully considers the scope of practice and skills of each of the team members. This is an example of which task-related concern? A. Appropriateness B. Fairness C. Efficiency D. Abilities

ANS: D A. This is incorrect. Appropriateness is a task-related concern. When making assignments it is essential to consider whether the individual assigned the task has the education to perform the task, and whether the task needs an individual with specific education and licensure. B. This is incorrect. Fairness is a relationship-oriented concern, taking into account the physical and emotional aspects of providing nursing care and striving to divide the workload evenly. C. This is incorrect. Efficiency is a task-related concern when RNs are making assignments. Appropriate delegation results in efficiency, but inappropriate delegation costs time and money and decreases efficiency. D. This is correct. Assignments should be individualized for each member of the nursing team. For each member of the team, the RN should consider the individual's knowledge and skill level, job description, role expectation, legal definitions, and individual strengths and weaknesses. This is tailoring the assignment to the abilities of each team member.

A nurse is caring for a patient diagnosed with acute exacerbation of COPD. Which of the following is the RN's priority assessment? A. Breath sounds B. Pedal pulses C. Location and intensity of pain D. Cardiac rate and rhythm

ANS: A A. This is correct. Airway, breathing, circulation, and vital signs are priority assessments. The patient has a breathing diagnosis; therefore, breath sounds take priority. B. This is incorrect. Pedal pulses are a circulatory assessment. A breathing assessment takes priority when the patient has a breathing diagnosis. C. This is incorrect. Airway, breathing, circulation, and vital signs are priority assessments over pain. D. This is incorrect. Cardiac rate and rhythm are circulation assessments. A breathing assessment takes priority when the patient has a breathing problem.

A chief nursing officer instructs a supervisor to complete staff scheduling for the month. Which of the following best describes this situation? A. Direct delegation B. Supervision C. Indirect delegation D. Assignment

ANS: A A. This is correct. Direct delegation occurs when an RN reassigns responsibility for performing a job to another person. The delegator retains responsibility to ensure the job is actually completed. B. This is incorrect. Supervision occurs when one individual holds authority over another. C. This is incorrect. Indirect delegation occurs when a list of duties is approved by an organization to be assigned to certain personnel. D. This is incorrect. Assignment is the allocation of duties that an individual is already authorized to do.

A staff nurse informed the charge nurse that she was 6 weeks pregnant. The charge nurse rearranged patient assignments so the pregnant nurse would not be caring for highly infectious patients. This scenario is an example of which relationship-oriented concern? A. Health B. Appropriateness C. Fairness D. Staff preference

ANS: A A. This is correct. Health is a relationship-oriented concern when making assignments. Special health needs should be taken into consideration. B. This is incorrect. Appropriateness is a task-related concern. When making assignments it is essential to consider whether the individual assigned the task has the education to perform the task, and whether the task needs an individual with specific education and licensure. C. This is incorrect. Fairness is a relationship-oriented concern when making assignments.Fairness takes into account the physical and emotional aspects of providing nursing care and striving to divide the workload evenly. D. This is incorrect. Staff preference is a relationship-oriented concern when making assignments. Staff preference takes into account the individual desires of the team members.

A new nurse is reviewing the legal constraints of nursing practice. Which of the following should the nurse review to determine legal boundaries to practice? A. State nursing practice act B. Professional nursing organization C. Institutional policies D. National Council of the State Boards of Nursing

ANS: A A. This is correct. State practice acts define the legal boundaries for nursing practice. B. This is incorrect. Professional nursing organizations define the standards of practice for nurses. C. This is incorrect. Institutional policies outline the job descriptions for members of the health-care team and serve to guide delegation decisions. D. This is incorrect. The National Council of State Boards of Nursing (NCSBN) writes the NCLEX licensure examination.

When organizing work for the day, which of the following should take priority? A. Clustered activities B. Activities that are time specific C. Delegating of assignments D. Peak energy time

ANS: B A. This is incorrect. Some activities are best performed in a cluster, but these are not the highest priority. B. This is correct. Activities that need to occur at a certain time and high-priority tasks are the biggest concerns. C. This is incorrect. Delegating assignments is an important task, but time-specific activities must be considered first. Also, it is important to remember that the RN is accountable even for tasks that have been delegated. D. This is incorrect. Taking peak energy time into consideration when planning activities for the day is a good recommendation, but time-specific activities take priority.

The charge nurse assigns a patient with a rare diagnosis to a newer nurse. This is an example of which relationship-oriented concern in making assignments? A. Staff preference B. Learning opportunities C. Compatibility D. Fairness

ANS: B A. This is incorrect. Staff preference is a relationship-oriented concern in making assignments that takes into consideration the individual desires of the team members. B. This is correct. Learning opportunities is a relationship-oriented concern when making assignments that considers the educational needs of team members, challenging them to take on new tasks. C. This is incorrect. Compatibility is a relationship-oriented concern in making assignments that focuses on team building efforts. D. This is incorrect. Fairness is a relationship-oriented concern that takes into account the physical and emotional demands of providing nursing care and strives to divide this workload evenly.

An ICU RN has been assigned to a high acuity patient who needs constant assessment and evaluation. What type of nursing is this RN performing? A. Team nursing B. Total patient care C. Functional nursing D. Primary nursing

ANS: B A. This is incorrect. Team nursing occurs when a group of nursing staff provide care for a cluster of patients. B. This is correct. Total patient care is when one RN cares for all the tasks involved with caring for one patient. C. This is incorrect. Functional, or task, nursing focuses on matching tasks with the best individuals to complete those tasks. D. This is incorrect. Primary nursing occurs when one nurse directs care for a patient during his or her entire hospital stay. The primary nurse and associate nurses provide care for the patient.

Safety is a main concern when delegating patient care assignments. Which of the following is true regarding delegation? A. The individual to whom a task is delegated is held accountable for the task. B. The RN may need to intervene even after patient care tasks have been delegated. C. If a licensed practical nurse (LPN) cannot complete a patient care task that was assigned to her by the RN, that task may be delegated to another member of the nursing team, as long as it is within that individual's scope of practice. D. After delegating a task, the RN does not need to supervise its completion.

ANS: B A. This is incorrect. The RN retains accountability for patient care even when delegating a task. B. This is correct. If the care provided is unethical or unsafe, the RN has a duty to intervene. C. This is incorrect. Assignments made by the RN may not be reassigned, even if it is within the scope of practice of the other team member. D. This is incorrect. RNs should train and supervise those to whom they delegate patient care tasks.

A nursing manager participates on a committee reviewing approved assignments for LPNs. Which of the following best describes this situation? A. Direct delegation B. Supervision C. Indirect delegation D. Assignment

ANS: C A. This is incorrect. Direct delegation occurs when an RN reassigns responsibility for performing a job to another person. The delegator retains responsibility to ensure the job is actually completed. B. This is incorrect. Supervision occurs when one individual holds authority over another. C. This is correct. Indirect delegation occurs when a list of duties is written into policy and approved by an organization to be assigned to certain personnel. D. This is incorrect. Assignment is the allocation of duties that an individual is already authorized to do.

A charge nurse is faced with a unit that is short staffed. The charge nurse reviews the tasks that need to be completed and assigns them to the best person. Which of the following types of nursing does this describe? A. Team nursing B. Total patient care C. Functional nursing D. Primary nursing

ANS: C A. This is incorrect. Team nursing occurs when a group of nursing staff provide care for a cluster of patients. B. This is incorrect. Total patient care is when one RN cares for all the tasks involved with caring for one patient. C. This is correct. Functional, or task, nursing focuses on matching tasks with the best individuals to complete those tasks. D. This is incorrect. Primary nursing occurs when one nurse directs care for a patient during his or her entire hospital stay. The primary nurse and associate nurses provide care for the patient.

An RN is supervising a team consisting of an LPN and a NAP. Which of the following patients should the RN see first? A. A patient on an insulin drip requiring hourly blood glucose checks B. A terminally ill cancer patient complaining of pain radiating throughout the abdomen C. A patient diagnosed with chronic obstructive pulmonary disease (COPD) who has become confused D. A patient with a serum potassium of 4.0

ANS: C A. This is incorrect. The RN should determine when the last blood glucose check was completed. However, airway, breathing, and circulation concerns take priority. B. This is incorrect. The patient's pain should be assessed and treated. However, airway, breathing, and circulation concerns take priority. C. This is correct. COPD is an airway and breathing concern. Confusion can be the result of decreased cerebral perfusion. This patient should be seen first. D. This is incorrect. The patient's serum potassium is within normal limits. Airway, breathing, and circulation concerns take priority.

A registered nurse (RN) instructs a nursing assistive personnel (NAP) to take vital signs for several patients. Which of the following best describes this situation? A. Direct delegation B. Supervision C. Indirect delegation D. Assignment

ANS: D A. This is incorrect. Direct delegation occurs when an RN reassigns responsibility for performing a job to another person. B. This is incorrect. Supervision occurs when one individual holds authority over another. C. This is incorrect. Indirect delegation occurs when a list of duties is approved by an organization to be assigned to certain personnel. D. This is correct. Assignment is the allocation of duties that an individual is already authorized to do.

The nurse is making assignments for the patient care team. Which of the following tasks should the RN complete herself? A. Blood glucose testing for a diabetic patient B. Feeding a client with dementia C. Administering the scheduled oral beta blocker to a patient with hypertension D. Providing medication to a patient complaining of pain after surgery

ANS: D A. This is incorrect. Taking routine blood glucose levels does not require assessment, planning, or evaluation. This task may be delegated. B. This is incorrect. Assisting with feeding does not require assessment, planning, or evaluation. This task may be delegated. C. This is incorrect. Scheduled oral medications do not require assessment, planning, or evaluation. This task may be delegated. D. This is correct. A pain assessment should be completed before providing the pain medication, and its effectiveness should be evaluated afterwards. Assessment and evaluation cannot be delegated.

A nurse is caring for a patient who has chronic obstructive pulmonary disease (COPD) in 2 days post-op after a laparoscopic cholecystectomy. Which intervention for airway management should the nurse delegate to an NAP? 1. Assisting the patient to sit up on the side of the bed 2. Instructing the patient cough effectively 3. Instructing the patient to use incentive spirometry 4. Auscultating breath sounds every 4 hours

1. Assisting the patient to sit up on the side of the bed

The patient with COPD has a nursing diagnosis of ineffective breathing pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision? 1. Observe how well the patient performs pursed-lip breathing 2. Plan a nursing care regimen that gradually increases activity intolerance 3. Assist the patient with basic activities of daily living 4. Consult with the physical therapy department about reconditioning exercises

1. Observe how well the patient performs pursed-lip breathing

A nurse is helping an NAP provide a bed bath to a comatose patient who is incontinent. Which of the following actions requires the nurse to intervene? 1. The nursing assistant answers the phone while wearing gloves 2. The nursing assistant log-rolls the patient to provide back care 3. The nursing assistant places an incontinence diaper under the client 4. The nursing assistant positions the client on the left side, head elevated

1. The nursing assistant answers the phone while wearing gloves

A nurse is caring for a patient who has a pulmonary embolus. The patient is receiving anticoagulation with IV heparin. What instructions should the nurse give the NAP to help the patient with activities of living? (multiple choice) 1. Use a lift sheet when moving and positioning the patient in bed 2. Use an electric razor when shaving the patient each day 3. Use a soft-bristled toothbrush or tooth sponge for oral care 4. Use rectal thermometer to obtain a more accurate body temperature 5. Be sure the patient's footwear has a non-slip sole when the patient ambulates

1. Use a lift sheet when moving and positioning the patient in bed 2. Use an electric razor when shaving the patient each day 3. Use a soft-bristled toothbrush or tooth sponge for oral care 5. Be sure the patient's footwear has a non-slip sole when the patient ambulates

The RN has been assigned to care for a group of patients on an inpatient unit. The RN is assigned an LPN and an NAP to assist in caring for the group of patients. Patients are assigned to the RN and nursing team for their entire length of stay on the unit. Which of the following types of nursing does this scenario best represent? A. Team nursing B. Total patient care C. Functional nursing D. Dyad primary nursing

ANS: D A. This is incorrect. Team nursing is when a group of nursing staff provide care for a cluster of patients. Although the team is providing care for a group of patients, there is a better description for this scenario, as the patient cluster remains the same for the patients' entire length of stay on the unit. B. This is incorrect. Total patient care is when one RN cares for all the tasks involved with caring for one patient. C. This is incorrect. Functional, or task, nursing focuses on matching tasks with the best individuals to complete those tasks. D. This is correct. Primary nursing occurs when one nurse directs care for a patient during his or her entire hospital stay. Today many hospitals use a dyad form of primary nursing, which uses support staff rather than all RNs. The principle remains the same. The patient will have the same staff providing care during the entire stay on the unit.