Exam 2 Leadership & Management practice questions & definitions/lists

Q19: The nurse and LPN have been assigned to care for clients on a neurology unit. Which nursing task is most appropriate to assign to the LPN? 1. Administer the adrenocorticotropic hormone to the client with multiple sclerosis. 2. Take the vital signs for the client who is experiencing status epilepticus. 3. Assist the client with Parkinson's disease to ambulate to the bathroom. 4. Assess the client newly admitted who has pneumonia and restless legs syndrome.

1. Administer the adrenocorticotropic hormone to the client with multiple sclerosis. Rationale: The LPN can administer medications to clients; therefore, this task is appropriate for the nurse to assign to the LPN. The client experiencing status epilepticus is an unstable client and the nurse should not assign this task to the LPN. The UAP could assist the client to the bathroom. Remember to assign/delegate tasks based on his or her education and job description. The nurse cannot assign assessment to the LPN.

Q18: The terminally ill client diagnosed with ALS (Lou Gehrig's disease) has a DNR order in place and is currently complaining of "pain all over." The nurse notes the client has shallow breathing and a P 67, R 8, B/P 104/62. Which intervention should the nurse implement? 1. Administer the narcotic pain medication IVP. 2. Turn and reposition the client for comfort. 3. Refuse to administer pain medication. 4. Notify the HCP of the client's vital signs.

1. Administer the narcotic pain medication IVP. Rationale: The nurse should administer the IVP narcotic pain medication even if the client has shallow breathing, with respirations of 8. A nurse should never administer a medication with the intent of hastening the client's death, but medicating a dying client to achieve a peaceful death is an appropriate intervention. Repositioning the client would not be effective for "pain all over." This is cruel to do to a client who is dying and has made himself or herself a DNR. The HCP has all the orders needed in place. There is no reason to notify the HCP.

Q6: The nurse is caring for a client diagnosed with Alzheimer's disease. Which nursing tasks should not be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Check the client's skin under the restraints. 2. Administer the client's antipsychotic medication. 3. Perform the client's morning hygiene care. 4. Ambulate the client to the bathroom. 5. Obtain the client's routine vital signs.

1. Check the client's skin under the restraints. 2. Administer the client's antipsychotic medication. Rationale: Checking the client's skin involves assessment; therefore, the nurse cannot delegate this assignment to the UAP. The nurse cannot delegate medication administration to a UAP. The UAP can perform routine hygiene care. The nurse must then make the time to assess the client's skin after completion of the hygiene. The UAP can ambulate a client to the bathroom. The UAP can take routine vital signs

Q4. The client is in the cardiac intensive care unit on dopamine, a vasoconstrictor, and B/P increases to 210/130. Which intervention should the intensive care nurse implement first? 1. Discontinue the client's vasoconstrictor, dopamine. 2. Notify the client's healthcare provider. 3. Administer the vasopressor hydralazine. 4. Assess the client's neurological status.

1. Discontinue the client's vasoconstrictor, dopamine. Rationale: The nurse should first discontinue the medication that is causing the increase in the client's blood pressure prior to doing anything else. The nurse should notify the HCP but not prior to taking care of the client's elevated blood pressure. The client may need a medication to decrease the blood pressure but the nurse should first discontinue the medication causing the elevated blood pressure. The nurse must first decrease the client's blood pressure prior to assessing the client.

Q13. The charge nurse on the rehabilitation unit is making assignments for the day shift. Which assignment would be most appropriate for the licensed practical nurse (LPN)? 1. Have the LPN call the HCP to obtain an order for a diet change. 2. Instruct the LPN to complete the admission assessment. 3. Ask the LPN to teach the client about a high-fiber diet. 4. Request the LPN to obtain the intake and output for the clients.

1. Have the LPN call the HCP to obtain an order for a diet change. Rationale: The LPN's scope of practice allows the LPN to take telephone orders. The LPN's scope of practice does not include initial assessment of an unstable patient (i.e. new admission). The registered dietician would be the most appropriate team member to teach about diets. The unlicensed assistive personnel (UAP) could obtain the intake and output; therefore, this is not an appropriate assignment for an LPN.

Q4: The client diagnosed with a cerebrovascular accident (CVA) has residual right-sided hemiparesis and difficulty swallowing, but is scheduled for discharge. Which referral is most appropriate for the case manager to make at this time? 1. Inpatient rehabilitation unit. 2. Home healthcare agency. 3. Long-term care facility. 4. Outpatient therapy center.

1. Inpatient rehabilitation unit. Rationale: This client should be referred to an inpatient rehabilitation facility for intensive therapy before deciding on long-term placement (home with home healthcare or a long-term care facility). The initial rehabilitation a client receives can set the tone for all further recuperation. This is the appropriate referral at this time. A home healthcare agency may be needed when the client returns home, but the most appropriate referral is to a rehabilitation center where intensive therapy can take place. A long-term care facility may be needed at some point, but the client should be given the opportunity to regain as much lost ability as possible at this time. The outpatient center would be utilized when the client is ready for discharge from the inpatient center.

Maslow's Hierarchy of Needs

1. Physiological needs 2. safety 3. love&belonging 4. esteem 5. self-actualization

Q12. The nurse and the unlicensed assistive personnel (UAP) are caring for a 74-year-old client who is 3-days postoperative right total hip replacement (THR). Which nursing task should be delegated to the UAP? 1. Place the abductor pillow between the client's legs. 2. Ensure the client stays on complete bed rest. 3. Feed the client the evening meal. 4. Check the client's right hip surgical dressing

1. Place the abductor pillow between the client's legs. Rationale: An abductor pillow is used for a client with a THR to help prevent hip dislocation and the UAP can place the pillow between the client's legs. This task is appropriate to delegate. The client should be out of bed and ambulating by the third day post-op to help prevent complications secondary to immobility, such as deep vein thrombosis (DVT) or pneumonia. Just because the client is elderly does not mean the client must be fed. There is nothing in the stem of the question that would indicate the client could not feed him or herself. The nurse should encourage independence as much as possible and delegate feeding the client to a UAP only when it is necessary. The nurse cannot delegate assessment to the UAP; therefore, checking the surgical dressing is not appropriate delegation.

Q12: The nurse is caring for clients in a long-term care facility. Which client should the nurse assess first after receiving the morning report? 1. The client diagnosed with Parkinson's disease who began to hallucinate during the night. 2. The client diagnosed with congestive heart failure who has 3+ pitting edema of both feet. 3. The client diagnosed with Alzheimer's disease who was found wandering in the hall at 0200. 4. The client diagnosed with terminal cancer who has lost 8 pounds since the last weight taken 4 weeks ago.

1. The client diagnosed with Parkinson's disease who began to hallucinate during the night. Rationale: The client diagnosed with Parkinson's disease who has begun to hallucinate may be experiencing an adverse reaction to common medications used to treat the disease. The nurse should assess this client first. Peripheral edema is expected in a client diagnosed with heart failure. This client does not need to be assessed first. Wandering and lack of sleeping are expected in a client diagnosed with Alzheimer's disease. This client does not need to be assessed first. Weight loss in a client diagnosed with terminal cancer is expected. The nurse should review the client's intake, food preferences, and pain control before making an intervention. Weight loss does not occur in a matter of minutes to hours, and this client's needs do not merit assessment before the client with a new problem.

The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first? 1. The client who has just been brought to the unit from the ED with no report of complaints. 2. The client who received pain medication 30 minutes ago for chest pain that was a level 3 on the pain scale. 3. The client who had a cardiac catheterization in the morning and has palpable pedal pulses bilaterally. 4. The client who has been turning on the call light frequently and stating her care has been neglected.

1. The client who has just been brought to the unit from the ED with no report of complaints. Rationale: This client may or may not be stable. The client may have "no complaints" at this time, but the nurse must assess this client first to determine whatever the complaint was that brought the client to the ED has stabilized. This client should be seen first.

Q8: Which client should the charge nurse assess first after receiving the change-of-shift report? (SCI Spinal Cord Injury) 1. The client with a C-6 SCI who is complaining of dyspnea and has a respiratory rate of 12 breaths/minute. 2. The client with an L-4 SCI who is frightened about being transferred to the rehabilitation unit. 3. The client with an L-2 SCI who is complaining of a headache and feeling very hot all of a sudden. 4. The client with a C-4 SCI who is on a ventilator and has a pulse oximeter reading of 98%.

1. The client with a C-6 SCI who is complaining of dyspnea and has a respiratory rate of 12 breaths/minute. Rationale: The client with dyspnea and a respiration rate of 12 has signs/symptoms of a respiratory complication and should be assessed first because paralysis at the C-6 level could cause the client to stop breathing if it progresses r/t to complication. The next option is a psychosocial need and should be addressed, but it is not priority over a physiological problem. A client with a lower SCI would not be at isk for autonomic dysreflexia; therefore, a complaint of headache and feeling hot would not be priority over an airway problem. The client with a pulse oximeter reading greater than 93% is receiving adequate oxygenation

Q10: The critical care charge nurse is making client assignments for the shift. Which client should the charge nurse assign to the graduate nurse who just completed the orientation? 1. The client with amyotrophic lateral sclerosis on a ventilator who is dying and whose family is at the bedside. 2. The client who has a closed head injury and has increasing intracranial pressure receiving intravenous osmitrol (Mannitol). 3. The client with a C-5 spinal cord injury who is experiencing spinal shock and is on the vasoconstrictor dopamine. 4. The client in status epilepticus

1. The client with amyotrophic lateral sclerosis on a ventilator who is dying and whose family is at the bedside. Rationale: The less experienced nurse could care for the client on a ventilator and console the family as needed. This client is not in a life-threatening situation and is stable for the condition. A client with increased intracranial pressure requires a more experienced critical care nurse. This client is unstable and requires a more experienced critical care nurse. Status epilepticus is a state of continuous seizure activity and is the most serious complication of epilepsy. This is a neurological emergency. This client should be assigned to a more experienced nurse.

Q17: The nurse is caring for clients in the emergency department. Which client should the nurse assess first? 1. The client with an epidural hematoma. 2. The client who had a seizure who is in the postictal state. 3. The client diagnosed with R/O encephalitis who has a headache. 4. The client with multiple sclerosis who has scanning speech.

1. The client with an epidural hematoma. Rationale: An epidural hematoma results from bleeding between the dura and the inner surface of the skull, and is a medical emergency. This client should be seen first. Postictal state is a sleepy state the client has after having a seizure. This client is stable; therefore, this client does not have to be assessed first. The client with encephalitis may have fever, headache, nausea, and vomiting. The client needs to be assessed but not prior to a head injury with active arterial bleeding. The client with multiple sclerosis is expected to have scanning speech; therefore, the nurse should not assess this client first.

Q3. The charge nurse in the cardiac critical care unit is making rounds. Which client should the nurse see first? 1. The client with coronary artery disease who is complaining that the nurses are being rude and won't answer the call lights. 2. The client diagnosed with an acute myocardial infarction who has an elevated creatinine phosphokinase-cardiac muscle (CPK-MB) level. 3. The client diagnosed with atrial fibrillation on an oral anticoagulant who has an International Normalized Ratio (INR) of 2.8. 4. The client 2 days' postoperative coronary artery bypass who is being transferred to the cardiac unit.

1. The client with coronary artery disease who is complaining that the nurses are being rude and won't answer the call lights. Rationale: The charge nurse is responsible for all clients. At times, it is necessary to see clients with a psychosocial need before other clients who have situations that are expected and are not life threatening. An elevated CPK-MB, cardiac isoenzyme, level is expected in a client with an acute myocardial infarction; therefore, the charge nurse would not see this client first. The INR is within the normal limits of 2 to 3; therefore, this client does not need to be assessed first. This client is being transferred to the cardiac unit; therefore, the client is stable and does not require the charge nurse to see this client first.

Q3: The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse? 1. The elderly client who is experiencing a stroke in evolution. 2. The client diagnosed with a transient ischemic attack 48 hours ago. 3. The client diagnosed with Guillain-Barré syndrome who complains of leg pain. 4. The client with Alzheimer's disease who is wandering in the halls.

1. The elderly client who is experiencing a stroke in evolution. Rationale: Because the client is having an evolving stroke, the client is experiencing a worsening of signs/symptoms over several minutes to hours; thus, the client is at risk for dying and should be cared for by the most experienced nurse. A transient ischemic attack by definition lasts less than 24 hours; thus, this client should be stable at this time. Pain is expected in clients with Guillain-Barré syndrome, and symptoms typically occur on the lower half of the body, therefore at this time of the illness a less experienced nurse could care for this client. A less experience nurse could care of this patient and thecharge nurse could assign this client to an unlicensed assistive personnel (UAP).

Which of the following tasks would you be willing to delegate to an UAP/NAP (nursing assistive personnel) or LPN/LVN? Use the South Carolina state Nurse Practice Act and the delegation decision tree as a reference for supporting rationale for each task. 1. Uncomplicated wet-to-dry dressing change on a patient 3 days post-hip replacement 2. Every 2-hour checks on a patient with soft wrist restraints to assess circulation,movement, and comfort 3. Cooling measures for a patient with a temperature of 104°F 4. Calculation of IV credits, clearing IV pumps, and completing shift intake/output totals 5. Completing phlebotomy for daily drawing of blood 6. Holding pressure on the insertion site of a femoral line that has just been removed 7. Educating a patient about components of a soft diet 8. Conducting guaiac stool tests for occult blood 9. Performing electrocardiographic testing 10. Feeding a patient with swallowing precautions (high risk of choking post cardiovascular accident) 11. Oral suctioning Tracheostomy care 12. Ostomy care 13. Subcutaneous Insulin administration

1. Uncomplicated wet-to-dry dressing change on a patient 3-days post-hip replacement Delegate to LPN/LVN: According to the Nurse Practice Act LPNs are able to monitor findings and contribute to the ongoing comprehensive assessment required by the RN. The key word in this task is it is "uncomplicated" and the patient is 3-days post-op. Therefore, with the information at hand the task is relatively predictable with minimal risk. The LPN can measure and document findings and report to the RN if there are any concerns regarding the dressing change. 2. Every 2-hour checks on a patient with soft wrist restraints to assess circulation, movement, and comfort Delegate to the LPN/LVN: It would be appropriate to delegate this task. LPNs can assist inevaluation responses to interventions as well as complete a focused assessment thatcontributes to the ongoing assessment, analysis and development of a comprehensive nursingplan by the RN. The LPN can assist in identifying the need for immediate assessment inresponse to the current client status and report to the RN. The LPN cannot perform initialassessments to determine a patient plan of care. Cooling measures for a patient with a temperature of 104°F Delegate to LPN or UAP depending on the cooling measures implemented by the nursing careplan. If there is an order for an anti-pyretic, the nurse may delegate administration of themedication to the LPN. If the cooling measures consist of cooling blanket placement etc, the RNor LPN could delegate this task to the UAP. Tasks such as these, do not require clinicaljudgement and there is little modification from patient to patient. According to the NCSBN,these tasks fall within the scope of the UAP. As always, based on the 5 rights of delegation, theRN/LPN should provide appropriate supervision. The LPN can complete a focused assessmenton the response to nursing interventions. The UAP cannot perform an assessment. 4. Calculation of IV credits, clearing IV pumps, and completing shift intake/output totals Delegate to LPN/LVN. This task is simply a collection of data to contribute to the ongoing assessment and plan of care implemented by the RN. There is no mention of IV medication administration. The nurse would just their nursing ju

Q5: The nurse and LPN are caring for a client diagnosed with a stroke. Which intervention should the nurse assign to the LPN? 1. Feed the client who is being allowed to eat for the first time. 2. Administer the client's anticoagulant subcutaneously. 3. Check the client's neurological signs and limb movement. 4. Teach the client to turn the head and tuck the chin to swallow.

2. Administer the client's anticoagulant subcutaneously. Rationale: The nurse should be the first one to feed the client in order for the nurse to evaluate the client's ability to swallow and not aspirate. The LPN could administer routine parenteral medications. This is the best task to assign to the LPN. This involves assessing the client; therefore, the nurse should not delegate this assignment to the LPN. Teaching is the responsibility of the RN.

Q14: Which task is most appropriate for the clinic nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Request the UAP to ride in the ambulance with a client. 2. Ask the UAP to escort the client in a wheelchair to the car. 3. Instruct the UAP to show the client how to use crutches. 4. Tell the UAP to call the pharmacy to refill a prescription.

2. Ask the UAP to escort the client in a wheelchair to the car. Rationale: If the client must be transferred from the clinic to the hospital, then the client is unstable and therefore should not be assigned to a UAP. The client is stable because he or she is being sent home; therefore, the UAP could safely complete this task. Showing the client how to walk with crutches is teaching, and the nurse cannot delegate teaching to the UAP. The UAP should not be calling a pharmacy because this is not within the scope of practice of unlicensed personnel.

Q9. The client is in ventricular tachycardia. Which intervention should the nurse implement first? 1. Defibrillate the client. 2. Assess the carotid pulse. 3. Administer epinephrine IVP. 4. Start cardiopulmonary resuscitation.

2. Assess the carotid pulse. Rationale: The nurse must first determine if the client has a pulse. If the client does not have a pulse then the nurse must defibrillate the client. If the client has a pulse, then the nurse should not defibrillate the client. The nurse must determine if the client has a pulse or not prior to taking any further action; therefore, this is the nurse's first intervention. This is the first medication administered during a code but the nurse first determines if the client has a pulse. This is appropriate intervention if the client has no pulse but the nurse first determines if the client has a pulse.

Q2. The nurse assesses erratic electrical activity on the telemetry reading while the client is talking to the nurse on the intercom system. Which task should the nurse instruct the UAP to implement? 1. Call a Code Blue immediately. 2. Check the client's telemetry leads. 3. Find the nurse to check the client. 4. Remove the telemetry monitor.

2. Check the client's telemetry leads. Rationale: The telemetry strip indicates an artifact, so there is no need for the UAP or any staff member to call a Code Blue, which is used when someone has arrested. The UAP should be instructed to check the telemetry lead placement; this reading cannot be ventricular fibrillation because the client is talking to the nurse over the intercom system. This telemetry is an artifact; therefore, the leads should be checked and the UAP can do this because the client is stable. In option 3, the UAP can take care of this problem; there is no need for the primary nurse to check the client. Finally, the strip indicates an artifact, but there is no indication that the client should be removed from telemetry.

Q7. The client on telemetry is showing ventricular tachycardia. Which action should the telemetry nurse delegate to the unlicensed assistive personnel (UAP)? 1. Have the UAP call the operator and announce the code. 2. Tell the UAP to answer the other call lights on the unit. 3. Send the UAP to the room to start rescue breaths. 4. Ask the family to step out of the room during the code.

2. Tell the UAP to answer the other call lights on the unit. Rationale: The nurse in the client's room notifies the hospital operator of a code situation. Answering the call lights of the other clients on the unit can be delegated to the UAP. In a hospital, the respiratory therapist assumes the responsibility for ventilations. The nursing supervisor is responsible for requesting the family to leave the room. The UAP does not have the authority to make this request.

Q1: The nurse has just received the shift report. Which client should the nurse assess first? 1. The client with Guillain-Barré syndrome who has ascending paralysis to the knees. 2. The client with a C-6 spinal cord injury who has autonomic dysreflexia. 3. The client with Parkinson's disease who is experiencing "pill rolling." 4. The client with Huntington's disease who has writhing, twisting movements of the face.

2. The client with a C-6 spinal cord injury who has autonomic dysreflexia. Rationale: The nurse would expect the client with Guillain-Barré syndrome to have ascending paralysis and the problem has just reached the knees, so the nurse should not need to assess this client first. The client with a C-6 SCI is expected to have autonomic dysreflexia but it is an emergency situation; therefore, the nurse should assess this client first. "Pill rolling," a hand tremor wherein the thumb and forefinger appear to move in a rotary fashion as if rolling a pill, is an expected clinical manifestation of Parkinson's; therefore, the nurse would not assess this client first. The client with Huntington's disease has chorea, which includes abnormal and excessive involuntary movements; therefore, this client would not be assessed first.

Q15. Which intervention should the nurse implement first for the client with a fractured femur who is suspected of having a fat embolism and acute shortness of breath. 1. Assess the client's bilateral breath sounds. 2. Encourage the client to cough and deep breathe. 3. Administer oxygen via nasal cannula. 4. Prepare to administer intravenous heparin therapy.

3. Administer oxygen via nasal cannula. Rationale: Assessing the client's breath sounds is an appropriate intervention, but if the client is in distress the nurse should intervene to help the client's body. Key word: SOB and requires understanding of a fat embolism. The client should be encouraged to cough and deep breathe but it will not help oxygenate the client, which is the priority for the client with a fat embolism. Oxygen must be administered to treat hypoxia, which occurs after a fat embolism; therefore, this is the nurse's first intervention. The HCP may or may not administer heparin therapy, but it would not be the first intervention the nurse would implement.

Q13: The client diagnosed with a cerebrovascular accident (CVA) is confined to a wheelchair for most of the waking hours. Which intervention is priority for the nurse to implement? 1. Encourage the client to move the buttocks every 2 hours. 2. Order a high-protein diet to prevent skin breakdown. 3. Get a pressure-relieving cushion to place in the wheelchair. 4. Refer the client to physical therapy for transfer teaching.

3. Get a pressure-relieving cushion to place in the wheelchair. Rationale: The client should be encouraged to move the buttocks to increase blood circulation to the area, but a wheelchair cushion used every time the client is in the wheelchair will help prevent pressure ulcers. A high-protein diet will assist with maintaining a positive nitrogen balance that will support wound healing, but it will not prevent pressure from causing a breakdown of the skin. All clients remaining in a wheelchair for extended periods of time should have a wheelchair cushion that relieves pressure to prevent skin breakdown. The more the client can move from the wheelchair to a chair to the bed, the more it will help decrease the possibility of a pressure ulcer, but a wheelchair cushion helps relieve pressure continuously.

Q6. The unlicensed assistive personnel (UAP) tells the nurse the client is complaining of chest pain. Which task should the nurse delegate to the UAP? 1. Call the healthcare provider (HCP) and report the client's chest pain. 2. Give a client some acetaminophen (Tylenol) while the nurse checks the client. 3. Get the client's medical records and bring them to the client's room. 4. Notify the client's family of the onset of chest pain.

3. Get the client's medical records and bring them to the client's room. Rationale: If the HCP is called, the nurse should perform this task, not the UAP. A UAP cannot take a telephone order; only a licensed nurse can take telephone orders. The UAP cannot administer a medication, not even Tylenol. The nurse should immediately go to the client's room and assess the client. Sometimes the nurse may need the client's chart and medical administration record (MAR) to assist in the assessment of findings. The UAP can bring these documents to the room. The UAP should not be asked to relay such information as outlined in option 4. This is the nurse's or HCP's responsibility.

Q9: The client with a C-6 spinal cord injury (SCI) comes to the emergency department complaining of a throbbing headache and has a B/P of 200/120. Which intervention should the nurse implement first? 1. Place the client on a telemetry unit. 2. Complete a neurological assessment. 3. Insert an indwelling urinary catheter. 4. Request a STAT CT scan on the head.

3. Insert an indwelling urinary catheter. Rationale: The client is experiencing autonomic dysreflexia, a complication of SCI above the T6, and the most common cause is a full bladder. Placing the client on telemetry is not the nurse's first intervention. Completing a neurological assessment is an intervention a nurse could implement, but it should not be the first for a client experiencing autonomic dysreflexia. Autonomic dysreflexia is a life-threatening condition and can be considered a medical emergency requiring immediate attention. The nurse should not assess but should intervene, and the most common cause is a full bladder. A CT scan of the head would be appropriate if the elevated B/P was secondary to a CVA, not due to a complication of a SCI.

Q1. The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain.

3. The 75-year-old client scheduled for a cardiac catheterization. Rationale: The first client is at high risk for complications related to necrotic myocardial tissue and will need extensive teaching; therefore, this client should not be assigned to a new graduate. Unstable angina means this client is at risk for life-threatening complications and should not be assigned to a new graduate. A new graduate should be able to complete a pre-procedural checklist and get this client to the catheterization lab. Chest pain means this client could be having a myocardial infarction and should not be assigned to a new graduate.

Q2: The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The UAP places the gait belt around the client's waist prior to ambulating. 2. The UAP places the client on the abdomen with the client's head to the side. 3. The UAP places her hand under the client's right axilla to help the client move up in bed. 4. The UAP praises the client for performing activities of daily living independently.

3. The UAP places her hand under the client's right axilla to help the client move up in bed. Rationale: Placing a gait belt prior to ambulating is an appropriate action for safety and would not require the nurse to intervene. Placing the client in a prone position helps promote hyperextension of the hip joints, which is essential for normal gait and helps prevent knee and hip flexion contractures; therefore, this would not require the nurse to intervene. The UAP placing hands under the axilla to reposition is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the clients should be pulled up by placing the arm underneath the client's back or using a lift sheet/drawsheet. The client should be encouraged and praised for attempting to perform any activities independently, such as combing hair or brushing teeth and does not require intervention.

Q5. The charge nurse on the cardiac unit is making shift assignments. Which client should be assigned to the most experienced nurse? 1. The client diagnosed with mitral valve stenosis. 2. The client diagnosed with asymptomatic sinus bradycardia. 3. The client diagnosed with fulminant pulmonary edema. 4. The client diagnosed with acute atrial fibrillation.

3. The client diagnosed with fulminant pulmonary edema. Rationale: The client with mitral valve stenosis can live with this diagnosis and it is not a life threatening condition. The client with asymptomatic sinus bradycardia is stable and because the client is not exhibiting any signs/symptoms, this client does not need to be assigned to the most experienced nurse. A client with fulminant pulmonary edema is experiencing an acute, life-threatening problem. The most experienced nurse should be assigned to this client. A client with acute atrial fibrillation does not take priority over the pulmonary edema at is not deemed acutely life threatening; therefore, this client would not be assigned to the most experienced nurse.

Q10. The nurse is working in an orthopedic unit. Which client should the nurse assess first? 1. The client who is 2 weeks postoperative open reduction and external fixation (ORIF) of the right hip who is complaining of pain when ambulating. 2. The client who is 10 days postoperative for left total knee replacement (TKR) who is refusing to use the continuous passive motion (CPM) machine. 3. The client who is 1 week postoperative for L3-L4 laminectomy who is complaining of numbness and tingling of the feet. 4. The client who is being admitted to the rehabilitation unit from the orthopedic surgical unit after a motor vehicle accident (MVA).

3. The client who is 1 week postoperative for L3-L4 laminectomy who is complaining of numbness and tingling of the feet. Rationale: The client having pain when ambulating after an ORIF of the hip is expected; this client would not need to be assessed first. The client should be ambulating and moving the left leg while in bed and would not need to be in the CPM machine 10 days postoperatively. Numbness and tingling of the legs are signs of possible neurovascular compromise. This client should be assessed first. The client being transferred should be assessed but would be considered stable; therefore, this client would not be assessed before a client experiencing possible neurovascular compromise.

Q11. The charge nurse on the acute care rehabilitation unit is making assignments for the shift. Which client should the charge nurse assign to the most experienced nurse? 1. The client with a full-thickness burn who is refusing to go to therapy. 2. The client with osteomyelitis who has bone pain and a fever. 3. The client with fractured tibia who has deep, unrelenting pain. 4. The client with low back pain radiating down the left leg.

3. The client with fractured tibia who has deep, unrelenting pain. Rationale: The client needs told the importance of therapy, but is not the most critical client; therefore, this client does not need to be assigned to the most experienced nurse. Bone pain and fever are expected clinical manifestations of the client with osteomyelitis, this client is stable and does not need to be assigned to the most experienced nurse. Deep, unrelenting pain is a sign of compartment syndrome, an acute, potentially life-threatening complication, in a client with a fracture; therefore, this client should be assigned to the most experienced nurse. The client with low back pain and radiating pain should be assessed, but this is not a sign of an acute complication; therefore, this client does not need to be assigned to the most experienced nurse.

Q20: A nurse is caring for the following clients on the Neurological Intensive Care unit. Which client should the nurse assess first? 1. The client with a C-6 SCI who is complaining of dyspnea and has crackles in the lungs. 2. The client with Guillain-Barré syndrome who is complaining ascending paralysis. 3. The client with traumatic brain injury who has a Glasgow Coma Scale score of 6. 4. The client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.

3. The client with traumatic brain injury who has a Glasgow Coma Scale score of 6. Rationale: The first client may be developing pneumonia and needs to be assessed but not prior to a client with a Glasgow Coma Scale of 6 which is life threatening. Ascending paralysis is an expected symptom of Guillain- Barré syndrome; while important, is not the higher priority. A 15 on the Glasgow Coma Scale indicates the client is neurologically intact, and a 6 indicates the client is not neurologically intact; and is in coma and should be assessed first. The RN can expect a client diagnosed with a CVA (stroke) to have some sequelae of the problem, including the inability to speak.

Q8. The telemetry technician tells the primary nurse the client in room 420 has a straight line. Which intervention should the primary nurse implement first? 1. Instruct the UAP to take the crash cart to room 420. 2. Tell the telemetry technician to call the Rapid Response Team. 3. Determine if the client has an apical pulse and blood pressure. 4. Check to see if the client has the telemetry leads on the chest.

4. Check to see if the client has the telemetry leads on the chest. Rationale: The crash cart would need to be brought to the room if the client was coding, but first the nurse should determine if the client's leads are on the chest. The Rapid Response Team is called if the client is in a potentially life-threatening situation and the nurse must first determine if the leads are on the client. The nurse should assess the client's vital signs but because the telemetry technician reports the client is flat-lined the nurse should first check if the leads are in place on the chest. The nurse should first determine if the client's telemetry leads are in place on the chest. If the leads are off then it will show as a flat line at the telemetry station. The telemetry technician cannot leave the station.

Which of the following tasks would you be willing to delegate to an UAP/NAP (nursing assistive personnel) or LPN/LVN? Use the South Carolina state Nurse Practice Act and the delegation decision tree as a reference for supporting rationale for each task. 4. Calculation of IV credits, clearing IV pumps, and completing shift intake/output totals

4. Delegate to LPN/LVN.

Q7: The nurse on the surgical unit is working with an unlicensed assistive personnel (UAP). Which task is most appropriate for the nurse to delegate to the UAP? 1. Change an abdominal dressing on a client who is 2 days postoperative. 2. Check the client's IV insertion site on the right arm. 3. Monitor vital signs on a client who has just returned from surgery. 4. Escort a client who has been discharged to the client's vehicle.

4. Escort a client who has been discharged to the client's vehicle. Rationale: The UAP cannot change abdominal dressings because the incision must be assessed for healing. The UAP cannot check the client's IV site. Remember, check is "assess." The nurse must monitor the vital signs on client recently returned from surgery to determine whether the client is stable; the UAP can take vital signs and report results to the nurse. The UAP can escort the client to the vehicle after discharge.

Q11: To which collaborative healthcare team member should the critical care nurse refer the client in the late stages of myasthenia gravis (MG)? 1. Occupational therapist. 2. Physical therapist. 3. Social worker. 4. Speech therapist.

4. Speech therapist. Rationale: The occupational therapist addresses assisting the client with ADLs and is appropriate but speech therapy is most appropriate in this situation. A physical therapist addresses transfer and movement issues with the client, but this would not be priority in the critical care unit. The social worker assists the client with discharge issues or financial issues, but this would not be appropriate for the client in the critical care unit. Speech therapists address swallowing problems, and clients with MG are at risk for aspiration; the speech therapist can help match food consistency to the client's ability to swallow and thus help enhance client safety. This referral would be appropriate in the critical care unit and is most appropriate given the options provided.

Q15: The community health nurse is triaging victims at the site of a disaster. Which client should the nurse categorize as black, priority 4? 1. The client who is alert and has a sucking chest wound. 2. The client who cannot stop crying and can't answer questions. 3. The client whose abdomen is hard and tender to the touch. 4. The client who has full thickness burns over 60% of the body.

4. The client who has full thickness burns over 60% of the body. Rationale: An alert client with a sucking chest wound should be categorized as red, priority 1, which means the injury is life threatening but survivable with minimal intervention. These clients can deteriorate rapidly without treatment. A client who cannot stop crying and cannot answer questions should be categorized as green, priority 3, which means the injury is minor and treatment can be delayed hours to days. These clients should be moved away from the main triage area. Clients with behavioral and psychological problems are included in this category. A client whose abdomen is hard and tender should be categorized as a yellow, priority 2, which means the injury is significant and requires medical care but can wait hours without threat to life or limb. Clients in this category receive treatment only after immediate casualties are treated. This client should be categorized as black, priority 4, which means the injury is extensive and chances of survival are unlikely even with definitive care. Clients should receive comfort measures and be separated from other casualties, but not abandoned.

Q16: The clinic nurse is triaging client's telephone calls. Which client should the nurse call first? 1. The client diagnosed with AIDS who has developed Kaposi's sarcoma. 2. The client diagnosed with dementia who is having difficulty dressing himself. 3. The client with trigeminal neuralgia who is having lightening-like shock to the cheeks. 4. The client whose friend has botulism who has vomiting and abdominal cramping pain.

4. The client whose friend has botulism who has vomiting and abdominal cramping pain. Rationale: .A client with AIDS would be expected to have Kaposi's sarcoma; therefore, this client would not need to be called prior to the botulism client. A client with dementia would be expected to have difficulty dressing; therefore, this client would not need to be called first. The classic feature of trigeminal neuralgia is excruciating pain described as a burning, knife-like, or lightning-like shock in the lips, upper or lower gums, cheek, forehead, or side of the nose. The nurse would not return this call first since the client is experiencing the normal signs/symptoms for the disease process. Botulism is the most serious type of food poisoning and the client is exhibiting signs/symptoms of it; therefore, the nurse should return this phone call first.

Q14. The nurse is assisting the client to use a cane when ambulating. Rank in order of performance the interventions the nurse would take. 1. Request the client to move the cane forward. 2. Move the weaker leg one step forward. 3. Ensure the client places the cane in the strong hand. 4. Move the stronger leg one step forward. 5. Apply a gait's belt around the client's waist.

5, 3, 1, 2, 4 Rationale: These are the best practices for helping a client use a cane when ambulating. 5. The gait belt is applied to ensure safety of the patient and the person assisting the client to ambulate. 3. The client should use the strong hand to control the assistive device. 1. The client should move the cane forward to provide a stable support for the weaker leg when it is moved. 2. The client should move the weaker leg even with the supportive cane while maintaining the stronger leg in place. 4. Finally, the stronger leg can move to a position even with the weak leg and cane.

3. Which of the following tasks should the RN delegate to the LPN? (SATA) A. Administration of a patient's routine morning oral medication B. Catheterization of a patient who has been unable to void C. Initiation of blood products for a patient with a Hgb of 6.8 D. Transporting a patient to x-ray to verify NG tube placement E. Performing an assessment on a new admission to the unit

A, B, D

2. Which of the following is a patient variable affecting staffing decisions? (SATA) A. Number of patients B. Family situation and needs C. Celebrity patients D. Stage of illness E. Interventions required

A, B, D, E

1. Which is not a reason to implement delegation? A. Improve the work performance of staff B. Decrease the registered nurse's accountability C.Achieve nursing goals D. Improve patient care outcomes

B. Decrease the registered nurse's accountability

2. After receiving bedside shift report, the RN should see which client first? A. Client who has Type II diabetes and has a fasting blood glucose of 90 B. Client who has a cast on their right arm and is reporting numbness C. Client 6 hours post- op whose temperature is 100F complaining of pain 5/10 D. Client with a urinary tract infection whose WBC was 12.0 this morning

B. Client who has a cast on their right arm and is reporting numbness

3. The nurse is triaging patients after a trauma incident. Which patient would the nurse consider emergent? A.Client with a dislocated shoulder and first degree burns on left leg B.Client with a concussion and superficial head laceration C. Client that is light- headed complaining of abdominal pain and distention D.Client with a fractured tibia

C. Client that is light- headed complaining of abdominal pain and distention

1. Which of the following in an unanticipated variable when the nurse manager is preparing for staffing? A. Current staffing vacancies B. Staff approved maternity leave C. Staff injury or illness D. Approved continuing education

C. Staff injury or illness

2. Which of the following tasks should the RN delegate to the UAP? A. Providing discharge instructions to a patient B. Assessing the incision of a patient just admitted from PACU C. Transporting a STAT blood culture specimen to the lab D. Evaluating progress of patient's range of motion

C. Transporting a STAT blood culture specimen to the lab

1. Which of the following clients in the Emergency Department would the RN see first? A. Client with sickle cell anemia with a pain score of 6/10 B. Client with COPD whose oxygen saturation is 95% on 2L nasal canal C. Client with nausea, vomiting, and diarrhea whose temperature is 101 F D. Client with new onset shortness of breath and chest pain

D. Client with new onset SOB and chest pain

Which of the following tasks would you be willing to delegate to an UAP/NAP (nursing assistive personnel) or LPN/LVN? Use the South Carolina state Nurse Practice Act and the delegation decision tree as a reference for supporting rationale for each task. 3. Cooling measures for a patient with a temperature of 104°F

Delegate to LPN or UAP

Which of the following tasks would you be willing to delegate to an UAP/NAP (nursing assistive personnel) or LPN/LVN? Use the South Carolina state Nurse Practice Act and the delegation decision tree as a reference for supporting rationale for each task. 2. Every 2-hour checks on a patient with soft wrist restraints to assess circulation,movement, and comfort

Delegate to the LPN/LVN

key delegation questions

Do Nurse Practice Act law, rules, or regulations restrict delegation in a given situation? Do organizational policies support delegation in a given situation? Does the delegate have sufficient knowledge and skill to carry out an intended delegation? Is the delegator authorized to delegate certain tasks? Is the delegator familiar with the knowledge, skills, abilities (KSAs) of the delegate to delegate safely? Does the patient's condition influence a normal decision- making process? Does the delegate know the untoward signs and symptoms for a specific patient in a specific situation? Will supervision be readily available?

ANA principles for nurse staffing

Health care consumer, interprofessional teams, practice environment, workplace culture, evaluation

4 key points of staffing

Patient need, RN nurse experience, practice environment, staffing guidelines

UAP scope of practice

assist client with ambulation, ROM, hygiene & ADLs feeding and oral care for stable clients (no risk of aspiration) record routine vital signs and I/Os positioning and linen change transfer/transport report client status and concerns to RN

communication related to delegation

giving information, giving direction, seeking clarity, seeking advice

RN scope of practice

initial assessment assessment of unstable clients adminster IV push, blood pdts, TPN, meds requiring titration/continuous monitoring access implanted devices interpret and analyze data requiring complex critical thinking care plan development initial and discharge teaching

LPN scope of practice

monitor RN findings and gather data (BP, HR, etc.) assessment of stable clients basic pt care (changing bandages, inserting catheters) report client status and concerns to RN/HCP care for stable clients with predictable outcomes (chronic, expected findings, ready for discharge, consistent labs) reinforce RN education administer most routine medications

May NOT Delegate

primary assessments, goal planning, evaluation, or initial patient education. Think the nursing process!! tasks that require specialized knowledge or clinical judgment

5 rights of delegation

right task right circumstance right person right direction/communication right supervision