LEADERSHIP LUZ WEEK 1.2
A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation? "Delegation provides appropriate resources for the client." "Delegation permits a designated individual to meet a goal on your behalf." "Delegation promotes discharge teaching activities for clients." "Delegation decreases health care costs."
"Delegation permits a designated individual to meet a goal on your behalf." Delegation is defined as directing the performance of others to accomplish goals of the nurse and the facility.
A nurse has assigned client care activities to an assistive personnel (AP). Which of the following statements by the AP indicates a need for assistance in establishing priorities? "I have my assignment and will start with room 1, then work my way to room 10." "I will give this client his meal tray first, as he is going early to physical therapy." "After breakfast, I will pack the belongings of clients who will be discharged this morning." "I will start by providing partial baths before breakfast."
"I have my assignment and will start with room 1, then work my way to room 10." The AP's statement does not include consideration of the tasks that need to be performed for each client, any time restrictions, or equipment to be organized.
A nurse in a long-term care facility has assigned a task to an assistive personnel (AP). The AP refuses to perform the task. Which of the following is an appropriate statement for the nurse to make? "I feel you are being inconsiderate of the other team members." "I have to let the director of nursing know about this situation." "I need to talk to you about the unit policies regarding client assignments." "You always get your choice of assignment and don't work your fair share."
"I need to talk to you about the unit policies regarding client assignments." This statement opens the conversation in a nonthreatening way and places the focus on the issue of policies rather than on any personal desire or characteristic of the individual.
A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict? "I need to talk to you about unit expectations regarding delegating and completing tasks." "Several staff members have commented that you don't do your fair share of the work." "If you don't do your share of the work, I will have to inform the nurse manager." "You have been very inconsiderate of others by not completing your share of the work."
"I need to talk to you about unit expectations regarding delegating and completing tasks." This statement opens the conversation in a nonthreatening way. The focus is on the issue of the equity of the assignment rather than on any personal characteristic of the individual.
A nurse manager is reviewing the Good Samaritan laws with a group of newly licensed nurses. Which of the following statements by the nurse manager is appropriate? "If you render aid in an accident, do not leave the scene until another competent person can take over." "Good Samaritan laws prohibit the victim from filing a lawsuit against the nurse." "Federal laws require a licensed nurse to render aid in an emergency." "A nurse who volunteers at a summer camp for children is covered by Good Samaritan laws."
"If you render aid in an accident, do not leave the scene until another competent person can take over." Once the nurse renders aid, she has entered a nurse-client relationship and must continue to provide care until competent help arrives.
A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step? "The client should be seen by a neurologist." "The client was found unconscious on the floor in her home." "There are no provider's prescriptions available." "The client is disoriented. Pupils are slow to respond to light."
"The client was found unconscious on the floor in her home." This statement is the background or context of the situation, which is the B step in the SBAR tool. The background portion should provide information that is pertinent to the current situation.
A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)? "The client's family members have been present most of the day." "The client's blood pressure and pulse have been fluctuating throughout the day." "The client discussed having prior thoughts of suicide." "The client works in the hospital radiology department."
"The client's blood pressure and pulse have been fluctuating throughout the day." Knowing the client and the stability of his condition is a criterion to consider when delegating to the AP. To promote client safety, the more stable clients should be chosen when delegating tasks to APs.
An assistive personnel (AP) comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which of the following statements by the nurse is appropriate? "There is a higher risk of infection for our clients associated with artificial nails." "You should know that artificial nails have a very unprofessional appearance." "I want you to review the facility's policy on personal attire before you begin the shift." "Why would you wear artificial nails to work when you know it's against the rules?"
"There is a higher risk of infection for our clients associated with artificial nails." Short, natural nails are less likely to harbor pathogens that can be harmful to clients. The CDC recommends health care workers avoid wearing artificial nails when caring for clients who are at risk for infection. Additionally, guidelines from the World Health Organization prohibit artificial nails for caregivers in every setting.
A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital signs to an assistive personnel (AP) for which of the following clients? A client who is 1 hr postoperative following a thyroidectomy A client who is 2 hr postoperative following an abdominal hysterectomy A client who is 3 days postoperative following gastric bypass surgery A client who is 3 days postoperative following a craniotomy
A client who is 3 days postoperative following gastric bypass surgery The client's physiologic status and stability of vital signs are considerations when assigning vital signs to an AP. This client is 3 days postoperative and his condition would have stabilized by this time.
An RN from the maternal-newborn unit is being floated to a medical-surgical unit. Which of the following clients should the charge nurse on the medical-surgical unit plan to assign to the RN? A client who has terminal end-stage renal disease A client who has acute pancreatitis A client who is one-day postoperative following a total abdominal hysterectomy A client who had a stroke and is to be admitted
A client who is one-day postoperative following a total abdominal hysterectomy The nurse who floats to another unit must have the skills to provide safe care to clients. This client is stable. This is an appropriate assignment for the RN.
A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances? A dependent adult admitted for the treatment of a spiral fracture A young adult client admitted for asthma and has track marks that may indicate IV drug abuse A young adult client admitted for acute glomerulonephritis following a viral infection An emancipated minor who has acute appendicitis and wants to leave the facility without treatment
A dependent adult admitted for the treatment of a spiral fracture Physical signs of dependent adult abuse include skeletal fractures, as well as burns, bruises, welts, and lacerations. Nurses are responsible for reporting suspicion of dependent adult abuse to the proper legal authorities within the state. It is important for the nurse to note that a competent older adult has the right to make his or her own decisions about pursuing legal action. Unless a client has been found to be legally incompetent, he or she is not classified as a dependent adult.
A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately? An adolescent female client who is belligerent and has slurred speech A toddler who has a laceration on his forehead and is screaming A middle adult male who is diaphoretic and reports epigastric pain A young adult with a painful sunburn of his face and arms
A middle adult male who is diaphoretic and reports epigastric pain When using the urgent vs. nonurgent approach to client care, the nurse should determine that caring for this client is the highest priority because diaphoresis and epigastric pain are manifestations of an acute myocardial infarction.
A nurse is teaching a class on torts. The nurse should include which of the following situations as an example of negligence? A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon. A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge. A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving. A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips.
A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon. Professional negligence is performing practice below the expected standard of care. It can be an act of omission, which is the failure to perform an act that a reasonable prudent person, under similar circumstances, would do. A reasonably prudent nurse would notify the provider of the neurovascular finding immediately.
A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first? A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min A toddler who has otitis media, a temperature of 39.2° C (102.6° F), and purulent ear discharge A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication
A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough A client who has acute epiglottitis, is drooling, and has an absence of spontaneous cough is unstable and requires immediate medical attention; therefore, this client is the priority and the nurse should have the provider care for this client first.
A nurse is planning to assign care activities to the assistive personnel (AP) on her team. Which of the following activities can the nurse assign to the AP? (Select all that apply.) Accompany a client who has depression to occupational therapy. Assess a client who has hypomania for exhaustion. Check the position of a client in soft wrist restraints. Set limits with a client who has mania. Sit with a client who has alcohol use disorder and whose last drink was five days ago.
Accompany a client who has depression to occupational therapy is correct. Accompanying a client to occupational therapy is within the scope of practice of an AP. Check the position of a client in soft wrist restraints is correct. Checking the position of a client in soft wrist restraints is within the scope of practice of an AP. The position can be reported to the nurse for follow-up. .Sit with a client who has alcohol use disorder and whose last drink was five days ago is correct. Sitting with a client is within the scope of practice of an AP. Any changes in the client can be reported to the nurse for follow-up.
A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply.) Ambulate an older adult client who has hypertension. Provide discharge instructions for a client who has a new skin graft. Perform an admission assessment on a client. Check a blood product with another nurse prior to administration. Weigh a client who has heart failure.
Ambulate an older adult client who has hypertension is correct. An AP can ambulate an older adult client who has hypertension. Weighing a client who has heart failure is correct. An AP can weigh a client who is stable
A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first? A school-age child who has diabetes mellitus and requires blood glucose monitoring An infant who has pertussis and is receiving oxygen via nasal cannula An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions A toddler who has both arms in casts and needs to be fed his breakfast
An infant who has pertussis and is receiving oxygen via nasal cannula Using the airway, breathing, circulation (ABC) approach to prioritizing client care, this infant should be assessed first because the infant has a compromised airway and requires oxygen.
A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following? An expert nurse provides testimony that the nurse should have handled the situation differently. Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation. The client's attorney states that injury to the client could have been prevented. The client's provider testifies the nurse was at fault for the injury.
Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation. The definition of negligence is practice that is below the standard of care. The benchmark for standard of care is what a reasonable, prudent person who has similar background and experience would do. Another staff nurse who has similar background is the correct person to provide testimony.
A nurse asks the assistive personnel (AP) to take a specimen to the laboratory and the AP refuses. Which of the following actions should the nurse take? Take the specimen to the laboratory. Report the AP to the charge nurse. Complete an incident report. Ask the AP about her concerns with the assignment.
Ask the AP about her concerns with the assignment. Reviewing the incident with the AP allows the nurse to understand the delegated task from the AP's perspective. The nurse should attempt to determine the underlying problem the AP has with the assignment.
A nurse has been reassigned from her regular area of work to a unit that is short staffed. Which of the following actions should the nurse take first? Ask what she will be assigned to do. Determine if she has the skills to complete the assignment. Identify her options. Notify the nurse manager about her concerns for client safety.
Ask what she will be assigned to do. Before accepting the assignment, the nurse should clarify the complexity of the assignment, such as how many clients she will be assigned to care for, what skills are needed, and what resources are available to her.
A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform? Administration of an enema Application of antiembolic stockings Assessing a client's sacrum for edema Assisting a client to cough and deep breathe
Assessing a client's sacrum for edema Assessment requires the nurse's specialized knowledge and cannot be delegated to an AP.
A nurse on a medical-surgical unit is preparing to contact a provider about a client's condition. The client is 6 hr postoperative from a total hysterectomy. The nurse notes the client's postoperative oxygen saturation is 94% and her apical heart rate is 110. The nurse should include information about the client's oxygen saturation level and heart rate in which component of the SBAR report? Situation Background Assessment Recommendation
Assessment The nurse should include his assessments in this level of the report. For example, the client's oxygen saturation level and the client's apical heart rate. The nurse can also include the amount of vaginal bleeding and the appearance of the wound dressing.
A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation? Assigning two assistive personnel (AP) to ambulate all clients Assigning a new graduate nurse to perform a wet-to-dry dressing change Assigning the most efficient AP to perform glucometer monitoring for each client Assigning the most competent RN to perform a central line dressing change
Assigning the most efficient AP to perform glucometer monitoring for each client Asking the most efficient AP to perform glucometer testing based on her efficiency in performing this task is an example of overdelegation. This can result in the AP becoming overworked and tired, thus decreasing productivity.
A nurse is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the licensed practical nurse (LPN)? Developing the plan of care for a client who has an amputation Evaluating the outcomes of a new postoperative client Analyzing data to identify issues for a client who has uncontrolled diabetes mellitus Assisting a client with crutch walking following knee replacement surgery
Assisting a client with crutch walking following knee replacement surgery Assisting a client with crutch walking is within the LPN's scope of practice.
A nurse is caring for an older adult client who has a terminal illness and is ventilator-dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles? Veracity Autonomy Fidelity Justice
Autonomy The issue here is the client's right to choose. The ethical principle of autonomy applies to an individual's right to choose and control what happens to him. Respecting autonomy requires the nurse to recognize the client's choice is based on personal values and those values do not have to be shared by the nurse.
A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take? Call the emergency response team. Seek immediate help from the risk manager. Call the provider for a stat DNR order. Respect the family's wishes and do nothing.
Call the emergency response team. Unless the provider writes a DNR order, the nurse should make every effort to revive the client. The nurse should follow the facility's protocol for enacting the emergency response procedure.
A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time? Check the client's medical record for the provider's prescription. Explain to the client that the provider prescribed the procedure. Assure the client that enemas are commonly prescribed for constipation. Inform the charge nurse that the client refused the enema.
Check the client's medical record for the provider's prescription. The nurse should use the client's medical record to verify the provider prescribed an enema for the client.
A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first? Collect a stool sample for ova and parasites from a school-age child Engage a toddler in play. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.
Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate. The infant who is postoperative from a surgical correction of a cleft palate is at risk for damage to the suture line and an elbow immobilizer decreases the risk of this complication; therefore, this is the task the AP should perform first.
A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client's consent form. The nurse's signature on the consent form indicates which of the following? Determines the client does not have a mental illness Confirms the client appears competent to provide consent Asserts the nurse has explained the risks and benefits of the procedure Records that the client's spouse agrees the procedure is necessary
Confirms the client appears competent to provide consent By signing as a witness on a procedural consent form, the nurse is confirming the client was the one who signed the consent form and that he seems to be competent to give consent.
A nurse is preparing to administer a prescribed medication to a client. Which of the following actions should the nurse plan to take to demonstrate client advocacy? Encourage the client to verbalize questions. Insist the client take prescribed medications. Inform the client that the medication is the same as taken at home. Tell the client that refusal of the medication is considered noncompliance.
Encourage the client to verbalize questions. The nurse acts as a client advocate by providing the client with information needed to make informed decisions regarding care.
A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take? Focus on providing care that prevents life-threatening emergencies. Reinforce discharge teaching to clients. Instruct the assistive personnel (AP) to focus on clients' ADLs. Stock additional unit supplies.
Focus on providing care that prevents life-threatening emergencies. The triage method in a disaster focuses on providing care to clients who have any immediate threat to life.
An assistive personnel (AP) tells the nurse manager that she observed a nurse on the unit removing a small amount of morphine from syringes prior to administering the medication to clients. Which of the following actions should the nurse manager take first? Gather data about the nurse's work performance and attendance history. Approach the involved nurse to discuss the behavior. Notify the risk manager. Refer the nurse to the board of nursing diversion program.
Gather data about the nurse's work performance and attendance history. The first action the nurse should take is to conduct an investigation and determine if the allegations are true.
A charge nurse is working with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care? Give positive feedback directly to the AP. Tell other nurses what an effective team member the AP is. Nominate the AP for the Employee of the Month award. Detail the AP's contributions to the nurse manager.
Give positive feedback directly to the AP. Positive reinforcement is one of the most effective ways to recognize an employee's ability and to motivate the employee.
A nurse working in an emergency department is caring for a client who has been exposed to sarin gas following a bioterrorism attack. Which of the following interventions should the nurse plan to take? Vigorously rub the skin following a decontamination shower. Initiate seizure precautions. Provide respiratory support with a plastic oral airway. Prepare to administer amyl nitrate.
Initiate seizure precautions. Symptoms of sarin gas exposure include neurologic responses including insomnia, impaired judgment, a loss of consciousness, and seizures. The nurse should anticipate the need for seizure precautions and should prepare the room with padding, suction equipment, and oxygen.
At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN? Providing postmortem care for a client Measuring a client's I&O Obtaining a client's weight Inserting a nasogastric tube for a client
Inserting a nasogastric tube for a client This is an appropriate task to assign to the LPN. It is not appropriate to assign this task to the AP.
A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following? Keeping an appointment with a client Allowing a new mother to hold her stillborn infant Confirming that a client going for surgery has signed a consent form Refusing to disclose information about a client to the media
Keeping an appointment with a client Fidelity is the duty to keep one's promises or word. Keeping an appointment the nurse has made with the client is an example of fidelity.
A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Perform wound irrigation for a client. Evaluate pain relief for a client following the administration of a pain medication. Measure and record intake and output for a client. Teach a client about low-sodium foods.
Measure and record intake and output for a client. The AP can measure and record intake and output (I&O) for a client. It is the nurse's responsibility to review the recorded results and respond as necessary.
A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)? Application of antibiotic ointment to the arm of a client who has dermatitis Obtaining medical history information from a stable client who is being admitted Monitoring vital signs of a client who had an appendectomy 12 hr ago Removal of the nasogastric tube of a client who has been receiving enteral feedings
Monitoring vital signs of a client who had an appendectomy 12 hr ago Delegating the monitoring of vital signs of a stable client 12 hr after surgery is an appropriate task for the AP because it does not involve assessment, specialized knowledge, or judgment.
A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles? Utility Paternalism Justice Nonmaleficence
Nonmaleficence The nurse is obligated to protect the client's confidential information. A breach of confidentiality can place the client at risk of harm. Nonmaleficence is the ethical duty to prevent harm to the client.
A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer? Delivering meal trays to clients in their rooms Assisting a client who has difficulty seeing the foods on the tray while eating Delivering a routine urine specimen to the laboratory Observing a postoperative client who is confused
Observing a postoperative client who is confused A nurse who uses delegation is responsible for delegating tasks to the right person. A volunteer does not have the training to intervene if this client tries to get out of bed or starts pulling at tubes. The observation of this client should be assigned to a member of the nursing staff.
An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP? Change the abdominal dressing. Obtain vital signs. Palpate for possible bladder distention. Observe the incision site.
Obtain vital signs. Obtaining vital signs is a skill within the scope of practice for an AP; therefore, the nurse can delegate this task to the AP.
A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply.) Provide discharge instructions to a confused client's spouse. Obtain vital signs from a client who is 6 hr postoperative. Administer a tap-water enema to a client who is preoperative. Initiate a plan of care for a client who is postoperative from an appendectomy. Catheterize a client who has not voided in 8 hr.
Obtaining vital signs from a client who is 6 hr postoperative is correct. Obtaining is a task that is appropriate to the education and skills of an LPN. Administering a tap-water enema to a client who is preoperative is correct. Administering a tap-water enema is a task that is appropriate to the education and skills of an LPN Catheterizing a client who has not voided in 8 hr is correct. Urinary catheterization is a task that is appropriate to the education and skills of an LPN.
A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first? Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. Apply a condom catheter to a client who is incontinent. Feed a client who has bilateral casts due to upper arm fractures. Deliver a clean voided urine specimen to the laboratory.
Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority task to delegate is the blood glucose monitoring for the client who has an insulin prescription. This task is time sensitive and should be completed first.
A nurse is planning to delegate a task to an assistive personnel (AP). Which of the following actions should the nurse plan to take? Assess the AP's ability to follow the client's teaching plan. Determine the social skills of the AP. Evaluate the ability of the AP to work with peers. Provide a clear description of the task to the AP.
Provide a clear description of the task to the AP. Providing a clear, concise description of the task, as well as the expected outcome, is essential when planning to delegate a task to the AP.
A nurse overhears two assistive personnel (AP) from the medical-surgical unit discussing a hospitalized client while in the cafeteria. Which of the following is the priority nursing action? Quietly tell the APs that this is not appropriate. Ask the nurse manager to provide an inservice program about confidentiality to the staff on the unit. Complete an incident report. Document the occurrence in a personal log.
Quietly tell the APs that this is not appropriate. The nurse has a professional duty to protect the client's confidential information. When using the urgent vs. nonurgent approach to client care, the nurse determines the priority is to stop the APs before there is an additional breach of confidentiality.
A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)? Wound drainage for culture Urine from an indwelling catheter Blood for PaCO2 Random stool specimen
Random stool specimen The nurse should delegate collection of a random stool specimen to the AP because it does not require the skills of a licensed nurse. However, the nurse, not the AP, should collect a stool specimen if a culture using a sterile swab is required.
A nurse is planning care for four clients and is assigning tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following should the nurse assign to the LPN? Complete an admission assessment for a client who has COPD. Measure I&O for a client who has an indwelling urinary catheter. Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty. Develop a plan of care for a client who has cholecystitis.
Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty. Reinforcing teaching with a client is within the scope of practice of a LPN; therefore, the RN should delegate this task to the LPN.
A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Which of the following tasks should the charge nurse reassign to a licensed nurse? Transporting a client who experienced a stroke 72 hr ago to the radiology department Providing a back rub to a client who has right-sided paralysis Removing and cleaning the cannula of a client who has a new tracheostomy Performing oral hygiene for a client who is 1 day postoperative following an amputation of the right arm
Removing and cleaning the cannula of a client who has a new tracheostomy Removing and cleaning the cannula of a client who has a new tracheostomy requires use of the nursing process, specialized knowledge, and clinical judgment; therefore, this task should be reassigned to a licensed nurse.
A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation? Right circumstances Right communication Right person Right supervision
Right supervision The nurse is demonstrating the right supervision when she assesses how the tasks are being accomplished and if any improvements are needed.
An RN is delegating care activities to a licensed practical nurse (LPN). Which of the following is the priority criterion the RN should consider when delegating? Agency policies for the LPN The documented experience level of the LPN The documented skill level of the LPN State Nurse Practice Act for the LPN
State Nurse Practice Act for the LPN According to evidence-based practice, the nurse should first consider the state Nurse Practice Act for the LPN. This act guides agency policies and provides the legal authority for nursing practice, including delegation.
A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes an incident report, which of the following actions should the nurse take? Make a copy of the incident report for the provider. Submit the incident report to the risk manager. Place the incident report in the client's chart. Document in the chart that an incidence report has been filed.
Submit the incident report to the risk manager. The purpose of an incident report is to provide information to the risk manager who will investigate the incident and work with other members of the health care team to control risks of client injury.
A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first? Take an arterial blood gas (ABG) specimen to the laboratory. Transport a client to the radiology department for an x-ray. Pass fresh water to clients on the unit. Obtain a routine urine sample from a newly-admitted client.
Take an arterial blood gas (ABG) specimen to the laboratory. When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority action is to take the ABG blood sample to the laboratory. ABG samples are placed on ice and must be transported to the laboratory immediately or the specimen will deteriorate, making any results inaccurate.
A charge nurse has assigned a group of clients to a licensed practical nurse (LPN). The charge nurse receives reports from her assigned clients about the LPN's lack of care. Which of the following actions should the charge nurse take? Review the LPN's personnel file. Discuss the LPN's behavior with other nurses on the unit. Talk with the clients who have reported the LPN's lack of care. Reassign some of the LPN's client care to assistive personnel.
Talk with the clients who have reported the LPN's lack of care. The charge nurse should investigate the allegations of misconduct to determine if disciplinary action is warranted.
When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation? The AP's ability to prioritize The AP has the knowledge and skill to perform the task The AP's rapport with clients The AP's ability to complete the task without assistance
The AP has the knowledge and skill to perform the task The right person is one of the five rights of delegation. The nurse should seek information from the AP about his individual skill level before delegating the task.
An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for? The client who requires frequent ambulation The client who is in protective isolation The client who is actively dying and requires IV pain medication The client who is 3 days postoperative and requires a dressing change
The client who is actively dying and requires IV pain medication The nurse should assume responsibility of this client because IV pain medications should be administered by RNs. Although this client may require less physical care, he may require more emotional care. The nurse should plan to spend extensive time with both the client and his family.
A nurse is planning to delegate tasks to a licensed practical nurse (LPN). Which of the following entities is important for the nurse to understand when delegating tasks to the LPN? The state Nurse Practice Act The National Association for Practical Nurse Education and Services The National Council of State Boards of Nursing Decision Tree The Omnibus Budget Reconciliation Act of 1987
The state Nurse Practice Act The state Nurse Practice Act identifies the skill or education level needed by a nurse to complete a task, as well as indicating items that can and cannot be delegated from a legal perspective.
A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer? Transporting a school-age client who is in traction to another department Playing a computer video game with an adolescent who has sickle cell disease Reading a book to a preschool client who has AIDS Rocking an infant who was admitted for croup
Transporting a school-age client who is in traction to another department To ensure client safety, the nurse is responsible for delegating tasks to the right people. The nurse should avoid assigning this task to the volunteer because the individual who performs this task must understand the principles of traction. A volunteer does not have the requisite skill to perform this task.
A charge nurse delegates to a licensed practical nurse (LPN) the task of changing a client's dressing. Several hours later the client reports the dressing has not been changed. Which of the following actions should the charge nurse take? Change the client's dressing. Reassign the task to another nurse. Verify the LPN knows how to do a dressing change. Report the issue to the unit manager.
Verify the LPN knows how to do a dressing change. The charge nurse should attempt to see the delegated task from the perspective of the individual being delegated to. This approach clarifies the reason for lack of action by the LPN.
