Leadership Practice 1

48. Planning to use SBAR communication tool when calling a provider. Which statement is appropriate for the "B" step?

"Client was found unconscious on the floor in her home." Rationale: This statement is the Background or context of the situation in the SBAR tool

13. Listening → report. Which statement indicates the nurse should assume TPC rather than assigning tasks to the AP?

"Client's BP and pulse have been unstable." Rationale: To promote client safety, the more stable clients should be chosen when delegating tasks to APs

55. A nurse is orienting a group of new grad nurses and explains purpose of delegation. Which is an appropriate statement?

"Delegation permits a designated individual to meet a goal on your behalf." Rationale: Delegation is defined as directing the performance of others to accomplish goals of the nurse and the facility.

19. Client is semicomatose; client's son reports the family does not want any heroic measures. How should the nurse respond?

"I will verify the status of the advance directives." Rationale: Advance directives are initiated by client while competent to identify health care wishes. Minimizes ethical dilemmas

20. A nurse is planning to assign care activities → AP. Which activities are appropriate for assignment?

-Accompanying a client with depression to occupational therapy -Checking the position of a client in soft wrist restraints -Sitting with a client who abuses alcohol whose last drink was two days ago Rationale: anything that requires special knowledge is not in the scope of practice

3.If a person at the nursery does not have the code, the appropriate intervention is to...

-Ask them to get the code from the mother

2.Incident Reports:

-Description of -Confidential -Incident/Actions taken -Risk mngmt investigations

3.Pulling a client up in bed with a draw sheet: Where should the nurse face?

-Direction that the client is moving

5.Appropriate actions if severe weather code activated:

-Draw shades, close drapes -Ambulatory pts → hallway -Turn weather radio on

1.Saftey factors →↑ Risk of falls:

-History -↓ vision -impaired memory -house slippers -kyphosis (Hump back)

5. Prep discharge, acute care facility → LTC, Info for discharge includes:

-History of coexisting & current illness -Level of functional abilities -Summary of physical, occupational, speech therapy W/treatment goals -Description of bladder/bowl plan W/ education provided -Stat upon discharge, mode of transportation, accompanies

4. Nursing support interdisciplinary collaboration:

-Open communication -Acknowledgement of knowledge & skills each member offers -Invitation of client/family to team meeting -request for referral

3. Nurse @ rehabilitation unit. Attends interdisciplinary meeting, client will be discussed (cervical spinal injury) Members include:

-Physical therapist -Occupational Therapist -Psychiatrist -nurse -vocational counselor -psychologist -Repertory Therapist

4.Morning blood glucose: 285 MG/DL; blood glucose before lunch 56 MG/DL; asymptomatic for hypoglycemia, Nursing Intervention:

-Recalibrate glucometer & recheck

8. Educational Foci for a new nurse:

-Skill proficiency -Assign to a preceptor -computerized charting -socialization into unit culture -facility policies/procedures

1.Hypersensitive med → wrong client. What are your next actions in order:

-V/S -Instruct pt. to stay in bed -Call HCP -Complete incident report -Notify risk management officer

1. Change of sift report at 7:00, Clients are to be seen in the order of...

1)Blood transfusion @ 0400 (infusion should not last longer than 4HRS) 2)Needs rapid onset insulin before 0800 trays 3)Analgesics QID PRN, last @ 0430 4)Colposcopy @ 1130, informed consent needs verification 5)Discharging today, needs reinforcing R/T dressing change (not time sensitive)

4.Preparing to insert IV catheter, morphine sulfate 10mg IV Bolus, number the time management principles:

1)Notify staff she will be unavailable 2)Envision procedure when collecting supplies 3)Draw up morphine before entering room, then admin immediately after IV established 4)Enter room, hang hygiene 5)Explain procedure, prep client

6.Actions to take when fire starts: (MASE)

1.Move clients 2.Activate alarm 3.Shut fire doors 4.Estinguish

46. Which tasks could a nurse assign to AP?

Obtaining V/S on clients who are stable Rationale: When delegating, consider the acuity of client, education level & knowledge of the person receiving assignment

21. A child admitting following an appendectomy is to be placed in a room with what other client?

A child with type 1 diabetes Rationale: The greatest risk to client following surgery is from infection. Both requires monitoring & teaching

3. A nurse is assigned a group of clients at the start of the shift. Which clients should the nurse plan to see first?

A client asking about his PCA pump which contains morphine Rationale: Using the priority (urgent vrs. Nonurgent) pain mngnt due to acute illness/injury = high priority

33. Listening to report on assigned clients at the beginning of the shift. Which information establishes a priority for the nurse?

A client had a catheter removed 7 hr ago and has not voided Rationale: urgent vs. nonurgent, he has not voided for 7 hours

11. There is a threat of flooding, and an internal disaster plan activated. Which should the nurse evacuate first?

A client receiving antibiotic IV therapy and wound vacuum care Rationale: medically stable but will require treatment following transport to another facility

7. Report: LVN reports to RN that a new AP has not totaled I&O. The RN then should...

Ask AP if he would like help Rational: The AP is new and may need help

10. The nurse is participating in a performance improvement study of a frequently performed procedure. The most helpful in aid in improvement:

Incidences of complications R/T procedure Rational: Most reliant info regarding procedure

29. A nurse on a surgical unit receives a call from a client's neighbor who requests update. How should the nurse respond?

Inform the neighbor that you cannot give out any information about client Rationale: HIPAA

35. A licensed PN is providing care to a client who has COPD. Which findings should be reported to the RN immediately?

Speaks in short phrases Rationale: inability to talk normally or complete a sentence without becoming SOB indicates difficulty maintaining O2 (Other signs: cyanosis, mental confusion, changes in mental status)

6. A nurse is caring for a client who is experiencing dysphagia. Which referral is appropriate at this time?

Speech therapist Rational: They assesses/makes recommendations for speech, language, & swallowing difficulties, referred for swallowing eval

50. A nurse should intervene when observing an AP do which with a client's medical record?

Tears a document with client information in half before disposing of it in a waste basket Rationale: Info security protocols include shredding any printed or written client info

22. A new LVN is planning to perform a procedure she has not done. What resources should the nurse use?

The policy and procedure manual for the unit Rationale: other sources may offer knowledge and assistance, but they may not describe the procedure within policy

4. A nurse manager is reviewing safe delegation practices w/nurses. Which is an appropriate statement by the nurse manager?

"All delegated tasks require follow-up to ensure compliance." Rationale: Monitoring of performance to ensure compliance is a principle of safe delegation practice

27. Assigned client care activities to AP. Which statement 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." Rationale: The AP's statement does not include consideration of the tasks that need to be performed for each client

25. Client undergoing hemodialysis who will be discharged. Which client statements most influence the current plan of care?

"My neighbor who takes me everywhere wrecked the car this morning." Rationale: clients requires transportation, communicate it to the interdisciplinary team, social worker may need to arrange transportation, the nursing staff will need to adjust teaching so client knows how to contact resources by phone

2. The manager is reviewing the accountability for client outcomes when delegating tasks AP(s). Which statement by the nurse is appropriate?

"The AP has no accountability for client outcomes when performing delegated tasks." Rationale: The nurse delegator remains accountable for patient outcomes when an AP has been delegated a task

40. A nurse is reinforcing teaching to the AP to set limits on a client's manipulative behavior after the nurse has reviewed the APs performance of a delegated task. Which responses by the AP indicate further teaching is needed?

"The goal for client is to ask directly for what he wants." Rationale: Eval of performance should focus on how the AP completed the task, not an eval of client outcomes

37. A nurse is caring for a client who is pregnant & refuses to receive chemo. Which is the best response for the nurse to give?

"This must be a difficult decision for you." Rationale: Therapeutic communication techniques encourage open, honest communication

3. What is the normal oxygen saturation?

90-100%

4.Community outbreak of meningitis, discharges needed, the most appropriate to discharge is...

-50yo M W/rotation cuff surgery, STABLE

2.Total hip arthroplasty, confused, moving leg into positions that could dislocate, what are your nursing interventions?

-Arm/Leg restraints immediately -Order from HCP -Family member sign for restraints

34. A charge nurse is delegating meal assistance after delivery of the dinner trays. Delegate which clients to the AP?

A client who has Parkinson's disease Rationale: The charge nurse should delegate meal assistance for client who has Parkinson's disease to the AP

5. A nurse is planning to assign obtaining V/S of postop client's → AP. She should assign obtaining for which clients?

A client who is 3 days postop following gastric bypass surgery Rationale: Client's physiologic status and stability of V/S; 3 days postop and his condition would have stabilized by this time

45. The RN is preparing assignments for the day shift. Which clients should the nurse plan to assign to the licensed PN?

A client who is two days postop following a hip replacement Rationale: This is an appropriate client to delegate to the PN because client should be physically stable at this time

14. A LVN receiving report. Which clients should cause the nurse to request a change of assignment?

A client who will be started on TPN during the current shift Rationale: delivered through a jugular/subclavian vein. TPN contains a high concentration of dextrose, can → hyperglycemia (polydipsia, polyphagia, and polyuria) bring the assignment → attention of the scheduling/charge nurse, negotiate a new assignment. If no resolution, take the concern up the chain of command. If a no resolution, an unsafe staffing complaint (assignment despite objection (ADO) or document of practice situation (DOPS); Failure to accept is considered abandonment

53. A nurse is assigned four postop clients. Which clients should the nurse address first?

A client whose BP at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg Rationale: 0800 BP = prehypertensive (systolic 129-139, diastolic 80-89), usual for postop, (stress of surgery, pain, and IV fluid); 1200 BP = norm (systolic 90-120, diastolic 60-80); Concern=BP drop may indicate internal bleeding, LVN report → RN

39. A nurse on a peds unit is reviewing her client assignment following the shift report. Which client should be seen first?

An infant with pertussis receiving oxygen via nasal cannula Rationale: Using the airway, breathing, circulation (ABC) approach to prioritizing client care

28. A nurse is collaborating on care for a client following a CVA. Which should be addressed by an occupational therapist?

Completing self-care Rationale: works with client to develop fine motor skills and coordination, such as improving hand strength

44. A nurse is organizing care for a group of clients. Which tasks could the nurse assign to the AP?

Assist a client who is 1 day postop following an appendectomy and requesting a bedpan Rationale: The AP should provide care to stable clients. Assisting a stable client with ADLs is appropriate for the AP

31. A nurse is planning care for a client who has anorexia nervosa. Which client goals have the highest priority?

Attain a weight that is greater than the 75th percentile for age and height Rationale: Maslow's hierarchy of needs, meeting the physiological need for adequate nutrition is the priority client goal

11. A nurse noticed that the unit manager does not intervene when there is a conflict between team members. The conflict resolution she is using is...

Avoiding/Withdrawing

2. What is continuity of care?

Completion of proper discharge from one facility to another

7. Change of shift report & delegating tasks → AP. The nurse should tell the AP to perform which task first?

Blood glucose monitoring of a client who has a prescription for short acting insulin prior to breakfast Rationale: Timing of client's insulin and breakfast make this the priority, may → rapid change to client's condition

23. A newly licensed nurse is planning to delegate tasks to an AP. Which tasks should the nurse plan to perform?

C. Observing a client's sacrum for edema Rationale: Observation is a data collection technique & requires specialized knowledge

15. A nurse is performing CPR on an adult who has suffered cardiac arrest at the grocery store. The nurse understands that the Good Samaritan law provides civil immunity if the nurse...

Certified in CPR and basic life support Rationale: Immunity when performing in an emergency situation

16. A nurse is implementing care for a client based on a clinical pathway. Which principles should the nurse follow?

Clinical pathways never replace clinical judgment Rationale: Clinical pathways (care plans, agency guidelines, or care maps) are designed to provide the standard, reduce mistakes, improve outcome and quality of care, and decrease duplication of effort, not all clients respond in the same way

43. A nurse is caring for a client who requires catheterization for a urine specimen. Client tells the nurse that she is concerned about her privacy during the procedure. Which actions should the nurse take to alleviate client`s concern?

Close the door and assure client that she will be covered Rationale: Client has expressed her concern for privacy, verbal and nonverbal communication

8. A nurse may assign the AP to collect V/S on which clients?

Congestive heart failure, young adult client 1 dy postop following appendectomy, 2 dys postop laparoscopic cholecystectomy Rationale: newly admitted client w/asthmaticus (life-threatening episode of airway obstruction & is often unresponsive to common treatment) is not stable. A client receiving a continuous IV infusion of regular insulin for diabetic ketoacidosis (hyperglycemia and acidosis; results in severe dehydration.) is incorrect

32. Which clients would benefit from an interdisciplinary client care conference? A client who is admitted with a diagnosis of...

Cystic fibrosis Rationale: thick, sticky mucus; R/F respiratory infections, intestinal obstruction, poor growth, malnourishment, cirrhosis of the liver, osteoporosis, and DM; Life expectancy ↓; Management is complex and requires a lifelong multidisciplinary approach

7. What is a Clinical pathway or care map used to direct?

Direct/focus on client care

18. A nurse asks the AP to take a specimen to the lab & AP refuses. Which action should the nurse take?

Discuss the incident with the AP Rationale: Reviewing the incident with the AP allows the nurse to understand the AP's perspective

42. Which actions jeopardize client confidentiality?

Discussing clients in the cafeteria, verbal report outside clients room, written report sheet into the hospital trash Rationale: HIPPA

12. Wrist restraints to a client who is confused and attempting to pull out a chest tube. Which would be an appropriate action?

Document client action that necessitated the restraints

54. A client expresses interest in learning more about advance directives. Which topics should the nurse anticipate discussing?

Enteral feeding tubes, Cardiopulmonary resuscitation, Durable power of attorney for health care Rationale: Organ donation is not part of; it includes living will

52. A severe storm resulted in an RN working with one AP on the unit. Which action by the nurse is appropriate?

Focus on providing care that prevents life-threatening emergencies Rationale: The hospital implements the triage method in a disaster, focuses on providing care to any immediate threats to life

6. Complete dressing change. During the change of shift report the new nurse would like a demonstration. The appropriate intervention for the nurse giving report is to...

Give report in conference room, then dressing change in client room

38. The informed consent was signed then states, "I have decided not to have the procedure." Which actions should be taken?

Inform the provider that client is withdrawing consent Rationale: Client has a right to refuse treatment

2. Older adult with fall precautions found on floor. The most appropriate action is to...

Inspect for injuries Rational: First check for neck immobilization, get back in bed, contact HCP

1. Preparing discharge of a CV Accident. Client has a gastrostomy tube. The nurse should check that...

Instructions are provided for eternal feedings at home

26. Cerebrovascular accident (CVA, stroke). Which actions will prevent deep-vein thrombosis (DVT)?

Place sequential compression devices bilaterally Rationale: DVT = most common type of thrombophlebitis; Treated with rest, anticoagulant therapy, sequential compression devices (SCDs); SCDs prevent blood stasis by ↑ circulation, Measure: middle of the foot - below the knee or thigh, worn in bed

10. A nurse, acute care setting, planning care, beginning of the shift. Which tasks should the nurse assign to the AP?

Monitoring V/S of a client who had an appendectomy 12 hr ago Rationale: appropriate activity for the AP since it does not involve assessment, specialized knowledge or judgment

1. AP reports → nurse that a client who returned → unit following an abdominal hysterectomy, dressing is saturated w/blood. Which tasks should be delegated to the AP?

Obtain V/S Rationale: The AP has been trained to and it is within the job description

36. A nurse assisting with discharge plan, a permanent trachea. The nurse should verify the availability of which equipment?

Oxygen, Suction machine, Replacement cannula Rationale: nurse reinforces teaching S/S airway obstruction, CPR, and abnormal findings; standard: one same size, one smaller

47. A nurse is caring for a client who does not speak English. How should the nurse reinforce teaching regarding a colonoscopy?

Provide a hospital-assigned interpreter to relay medical information Rationale: Providing a hospital-assigned interpreter to relay medical information is the most appropriate means for communication. Interpreters should be available on call by phone or in person

51. A nurse is obtaining blood samples for type and cross-match from two clients both scheduled for minor surgical procedures. Later, the nurse is convinced the labels were inadvertently switched. What is the appropriate action?

Redraw both specimens, label them carefully, and inform the blood bank of the error Rationale: assure client safety by redrawing, blood bank will be notified so the other two specimens can be discarded

30. Client is confused, combative, & requires jacket/wrist restraints. To prevent injury, which actions should the nurse take?

Remove the restraints and observe client's extremities for circulation every 4 hr Rationale: helps prevent nerve and musculoskeletal injuries as a result of poor circulation

56. A nurse is working w/AP and reviewing the list of tasks that have been delegated. Which tasks requires clarification?

Removing and cleaning the cannula of a client with a new tracheostomy Rationale: requires assessment, knowledge, judgment and skill, and is a task that cannot be delegated by the nurse

24. A nurse is providing pin site care to a client in skeletal traction. Which actions should prompt the charge nurse to intervene?

Removing the crust around pin sites during cleaning Rationale: Crusting at the pin site should not be removed because this provides a natural barrier from bacteria

9. A nurse is reviewing all occurrence reports submitted last month. She should identify that what should be reported?

Reports routinely omit the names of witnesses to the occurrence Rationale: A complete description of the occurrence should be included, along w/ names of any witness's → incident

5. Charge nurse is making assignments. The nurse should consider...

Retaining care activities that only an RN can delegate other activities as appropriate

49. A nurse is caring for a client. How should the nurse verify client's durable power of attorney?

Review paperwork completed upon admission Rationale: The legal document should be placed in client's current medical record upon admission

17. A charge nurse has assigned a group of clients to a newly licensed LVN. The charge nurse observes the LVN chatting sociably with peers, left the unit without communicating, reports from clients about lack of care. Which is an appropriate action?

Review the LPN's assignment in relation to other nurses on the unit Rationale: Reviewing the LVNs assignments, allows the charge nurse to see the delegated task from the LVNs perspective

41. A nurse checks w/personnel through the day to determine if they are completing tasks. What right of delegation?

Right supervision Rationale: the right supervision when she assesses how the tasks are being accomplished and if any improvements are needed

12. A nurse received performance appraisal by unit manager. The unit manager should be reported to his supervisor about...

Verbal concerns provided by staff incorporated into data Rational: Only use data that has been formally documented

9. A nurse is preforming a performance improvement study for patient controlled analgesia (PCA). The nurse should...

bring it to the nurses' attention that she is documenting incorrectly & Offer assistance. Rational: If this does not work, contact nurse manager