PC3 Exam 2

Which aspects are included in how nurses develop nursing judgment? SATA. A) Academic experience B) Use of experience to help form an opinion C) Analysis of information to help arrive at a decision D) Leadership style E) Level of administrative experience as opposed to being a staff nurse

A, B, C

An RN refuses to delegate any patient care tasks to other members of the nursing unit staff preferring to complete all tasks herself. What type of delegation practice would this demonstrate? A) Underdelegation B) Effective delegation C) Overdelegation D) Recognition of right person

A) Underdelegation

Which factor would the nurse consider when setting priorities for care during a shift? SATA. A) Client acuity B) Unit organization C) Availability of resources D) Own experience and expertise E) Philosophies and models of care

A, B, C, D, E

In which order are the steps of a primary survey performed to assess a client with severe injuries from a bomb blast? Correctly order all options from first to last. A) Airway B) Breathing C) Circulation D) Exposure E) Disability

A, B, C, E, D

Which order would the nurse perform from first to last when prioritizing care upon entering a client's room and noticing the trash on fire? Place all options in the correct order. A) Rescue clients in immediate danger B) Activate the fire alarm C) Extinguish the fire D) Close doors and windows

A, B, D, C

According to priority, in which order would the nurse perform care activities for a client with complete partial seizures? Place all options in the correct order. A) Maintaining airway B) Assessing VS C) Recording the time and duration of seizure D) Performing neurological checks

A, C, B, D

Average Daily Census (ADC)

Average total number of patients when census is taken (at midnight) over a given period of time, such as weekly, monthly, or yearly

Which nursing intervention is the priority for a client with stroke who is transitioned from the ER to other settings? A) Monitoring VS B) Reassuring the client and family C) Assessing the LOC D) Monitoring the specific client manifestations of stroke

C) Assessing the LOC

Authority

A legal source of power; the right to act or command the actions of others and to have them followed

Appropriate Staffing

A match of registered nurse expertise with the needs of the recipient of nursing care services in the context of the practice setting and situation

The client with which condition is instructed to limit the number of visitors as a safety priority? A) Client undergoing brachytherapy B) Client undergoing prostate surgery C) Client who underwent uterine artery embolization D) Client who underwent an open spinal reconstructive surgery for scoliosis

A) Client undergoing brachytherapy Rationale: Brachytherapy for breast cancer contains radiation in a temporary implant so the client undergoing brachytherapy should limit visitors as a safety precaution

Which statement best reflects the concept of accountability with regard to delegation of tasks? A) Nursing state practice acts do not require nurses to be held accountable for their actions B) Accountability exists at both nursing and organizational levels C) An organization's obligation to accountability is based on its ability to offer quality care regardless of nurse staffing D) The competency of the nurse is not considered as being relevant to accountability

B) Accountability exists at both nursing and organizational levels

Which late effect of radiation therapy on the heart would the nurse monitor as a priority? A) Trismus B) Pericarditis C) Lymphedema D) Pulmonary fibrosis

B) Pericarditis

Accountability

Being responsible and answerable for actions or inactions of self or others in the context of delegation

Which nursing care delivery system works well in emergency situations that necessitate prioritization of care? A) Team nursing B) Primary nursing C) Functional nursing D) Client-centered nursing

C) Functional nursing

Assignment

Describes the distribution of work that each staff member is responsible for during a given time period

Underdelegation

Failure to transfer full authority to perform a task or a failure to provide clear direction to the delegate

Workload

Number of nursing staff required to deliver care for a specific time period and is dependent on patient care needs

Primary Nursing

RN managed care for a group of patients for 24 hours a day, 7 days a week throughout their hospital stay

Non-Productive Time

Refers to benefit time, such as vacation hours, holiday time, sick hours, education time, and jury duty

Skill Mix

Refers to the varying levels of education, licensure, certifications, and experience of the staff

Which priority teaching intervention would the nurse include in the care plan for a client who has insomnia? A) Medication administration and procedures B) Sleep and cognitive changes C) Dietary measures to be followed at night D) Non-pharmacological measures, including sleep techniques

cognitive

Nursing Hours Per Patient Day (NHPPD)

Represents the nursing care hours provided to patients by nursing personnel over a 24-hour period

Patient-Focused Care

Revolves around a multi-skilled team approach to nursing care, the RN functions as the patient care manager and coordinates all patient activities

Right Direction/Communication

The nurse provides a clear, concise description of the task, including its objectives, limits, and expectations

Right Supervision/Evaluation

The nurse provides feedback to the delegate as well as appropriate monitoring, evaluation, and intervention as needed

Responsibility

The obligation one has to accomplish work

5 Rights of Delegation

-Right task -Right circumstance -Right person -Right direction/communication -Right supervision/evaluation

Which examples represent improper use of delegation in the clinical setting by an RN, LPN, or UAP? SATA. A) UAP delegating a task to an LPN B) RN delegating a task to a UAP or an LPN C) LPN delegating a task to an RN D) RN delegating a task to an RN E) UAP delegating a task to an RN

A, C, E

Functional Nursing

A means to accomplish patient care with assistance of ancillary personnel

Which actions should not be delegated to an LPN on a medical unit in a hospital setting by a registered nurse? SATA. A) Initiating a blood transfusion B) Inserting a urinary catheter C) Administering chemotherapy infusion D) Completing initial admission assessment E) Performing post-op dressing changes

A, C, D

Full-Time Equivalent

A unit that measures the work of one full-time employee for 1 year (52 weeks) based on a 40-hour work week, equating a total of 2080 paid hours per year

Which question would the nurse ask first of the witnesses who accompanies a rescued drowning victim to the ED? A) "How long was the client underwater?" B) "Was the client drinking alcohol today?" C) "What is the client's name and date of birth?" D) "Did the client dive head first into the water?"

A) "How long was the client underwater?"

Non-licensed staff members (UAP) have asked for a meeting with the nurse manager as they are unhappy with how some of the nursing staff (RN) has been delegating tasks with regard to patient care. Which statement if made by a non-licensed staff member would indicate that additional instruction is needed for the nursing staff with regard to effective delegation principles? A) "The RN told me that I couldn't obtain a urine specimen from a patient." B) "I was told by the RN that I had to wait until the order was written in the patient's chart before I could act on it." C) "The RN told me that I should wait until after lunch before I gave the patient AM care as the patient had just been medicated for pain." D) "The RN told me that I had to change all of the bed linen for the patients before I went home at the end of the shift."

A) "The RN told me that I couldn't obtain a urine specimen from a patient."

Which nursing intervention is the highest priority for a client experiencing symptoms of premenstrual syndrome? A) Advising the client to have adequate rest B) Teaching the client stress reduction techniques C) Instructing the client to follow the medication therapy D) Encouraging the client to perform aerobic exercises

A) Advising the client to have adequate rest

Which nursing action has the highest priority when caring for a client receiving nitroglycerin for the treatment of angina? A) Asking the client to sit or stand slowly B) Monitoring the client's urine output frequently C) Advising the client to report when experiencing a headache D) Reporting the HCP if pain does not subside after 5 minutes

A) Asking the client to sit or stand slowly

Which intervention is the highest priority nursing action for a client with a scorpion bite? A) Assessing the client's vital signs B) Applying an ice pack to the sting site C) Contacting the poison control center D) Covering the client with a cooling blanket

A) Assessing the client's vital signs

Which client would be provided immediate care based on priority among four clients who sustained injuries in an accidental fire? A) Client with burns to the head B) Client with burns to the chest area C) Client with burns to the lower extremities D) Client with burns to the upper extremities

A) Client with burns to the head

Which action is the priority after a home care nurse arrives to visit a client who states he or she has attempted suicide by ingesting paint thinner and then collapses? A) Contact 911 B) Induce vomiting C) Call the poison control center D) Place the client in a side-lying position

A) Contact 911

Which aspect of total client care needs to be taken into consideration used on a 24-bed care area? A) Cost of nurses B) Training needs C) Documentation D) Client satisfaction

A) Cost of nurses

Which nursing intervention would the first priority for a client hospitalized with an overdose of benzodiazepines and presenting with a respiratory rate less than 10 breaths per minute? A) Give oxygen B) Secure airway C) Administer flumazenil D) Assess the IV site

A) Give oxygen Rationale: O2 should be given as the first priority intervention for clients with a respiratory rate below 10 breaths per minute as a result of an overdose of benzodiazepines. Securing the airway is done before starting benzodiazepine antagonist therapy.

Which educational topic is a high priority for the nurse providing education to a client with systemic lupus erythematosus? A) Instructing about ways to protect the skin B) Helping the client identify coping strategies C) Teaching methods to monitor body temperature D) Teaching about the effects of the disease on lifestyle

A) Instructing about ways to protect the skin

Which intervention would the nurse perform as a priority for a client hospitalized with respiratory distress because of an overdose of antidepressant medications? A) Intubating the client B) Administering an antidote C) Administering activated charcoal D) Initiating electrocardiogram monitoring

A) Intubating the client

A nurse manager is educating a staff nurse with regard to the five rights of delegation. Which statement by the staff nurse indicates that additional training is needed with regard to right supervision or evaluation? A) Once a task has been delegated, the nurse is absolved of responsibility B) Nurses should provide feedback relative to task completion C) It is important to provide clear directions relative to task delegation D) Performance of the delegated task should be monitored

A) Once a task has been delegated, the nurse is absolved of responsibility

What does the nurse consider to be the priority nursing intervention for a client on diuretic therapy who has developed metabolic acidosis? A) Preventing falls B) Monitoring electrolytes C) Administering antiemetics D) Adjusting the diuretic therapy

A) Preventing falls

Which priority intervention would the nurse expect to begin for a post-op care client with hypotension? A) Start O2 therapy B) Inspect the surgical incision C) Administer IV fluid boluses D) Administer vasoconstrictive agents

A) Start O2 therapy

A client with severe abdominal pain is on meperidine treatment and later develops seizures. Which intervention is given highest priority? A) Stop administration of meperidine B) Administer transdermal scopolamine C) Administer oxygen through facial mask D) Monitor respiratory status and sedation level

A) Stop administration of meperidine

A post-op client with a tracheostomy tube in place suddenly develops noisy, increased respirations and an elevated heart rate. The nurse would take which action immediately? A) Suction the tracheostomy B) Change the tracheostomy tube C) Readjust the tracheostomy rube and tighten the ties D) Perform a complete respiratory assessment

A) Suction the tracheostomy

Which delivery system was developed to provide care through others as an adaptation to functional nursing? A) Team B) Primary C) Case management D) Differentiated practice

A) Team

Which nursing action is the priority when the nurse discovers in an admission assessment that a client has a stage 1 pressure ulcer? A) Turn and reposition the client every 2 hours B) Cover the ulcer with an occlusive, transparent dressing C) Clean the ulcer with hydrogen peroxide and leave it open to air D) Provide the client with a diet high in vitamin C, zinc, and protein

A) Turn and reposition the client every 2 hours

In which priority order would the actions of care be implemented for clients in an emergency? Place all options in the correct order. A) Initiate contact with the client B) Identify need for emergent care C) Begin immediate treatment D) Determine interventions for nursing care

A, B, D, C

After an assessment of the extent of the injury, in which order would the nurse perform interventions according to priority for a client who sustained a soft tissue injury while playing sports? Place all options in the correct order. A) Assessing neurovascular status B) Applying a compression bandage C) Elevating the involved limb D) Obtaining x-rays of the extremity

A, C, B, D

Which is the correct order of steps the nurse will implement when providing care to a client who has experienced trauma? Place all options in the correct order. A) Clear the airway B) Provide supplemental O2 C) Perform chest compressions D) Protect the cervical spine

A, D, B, C

Mindful Communication

An active process in which those involved are focused on attending to, responding to, and perceiving information

Right Person

Assess and verify the competency of the health care team member, task must be within their scope of practice

RN Scope of Practice

Assessments, nursing diagnosis, interventions, evaluations, patient teaching, discharge planning, evaluating and monitoring changes in patient status, and complex patient care that requires special knowledge and judgment

Which situation provides an example of the right circumstances as defined by the five Rights of Delegation? A) Completion of the task does not require nursing judgment B) Assessing needs of the population in the context of available resources C) Identifying competency level D) Providing correct information to a patient

B) Assessing needs of the population in the context of available resources

Which nursing action is the highest priority for a client who has a suspected pelvic fracture as the result of a motor vehicle accident? A) Logrolling for transfers B) Inspecting the genitalia C) Preparing for pelvic exam D) Administering prescribed pain medication

B) Inspecting the genitalia

An RN is working on a medical-surgical unit functioning as a team leader for five patients with an LPN and a CNA. Which action should not be delegated to the CNA? A) Positioning the patient for comfort by raising the head of the bed B) Performing a pain assessment C) Assisting the patient with transfer from bed to chair D) Offering the patient fluids

B) Performing a pain assessment

A physician has ordered a rectal suppository to be administered to a 25-year-old male patient. The RN delegates this task to the LPN. The LPN would prefer not to complete this task. The RN tells the nurse manager about this issue. How would the nurse manager interpret this refusal by the LPN to perform a delegated task? A) Underdelegation B) Possibility of a delegate-related barrier C) Overdelegation D) Possibility of a delegator-related barrier

B) Possibility of a delegate-related barrier

Which consideration is made first when providing emergency care for a drowning client? A) Administer oxygen B) Safely rescuing the client C) Preventing aspiration of gastric contents D) Performing CPR

B) Safely rescuing the client

Which nursing intervention would the nurse perform immediately for the client with a head injury and a Glasgow Coma Scale score of 9? A) Intubate the client B) Stabilize the cervical spine C) Administer O2 via a nonrebreather mask D) Control external breathing with a sterile pressure dressing

B) Stabilize the cervical spine Rationale: A client with a head injury may suffer shortness of breath. The client's cervical spine should be stabilized immediately to maintain the airway.

Which patient activity could be performed by either an RN or an LPN or delegated as a task even if there is a UAP present on the unit? A) Initiation of blood transfusion B) Tracheostomy care C) Assisting a patient with feeding D) Obtaining daily weight

B) Tracheostomy care

Which skills are essential for the nurse who is setting priorities for client care? SATA. A) Evaluation B) Assessment C) Critical thinking D) Case management E) Clinical decision-making

B, C, E

Which tasks would a charge nurse using the functional nursing model assign to the LPN? SATA. A) Showering two clients after breakfast B) Administering topical and oral medications C) Providing discharge instructions to three clients D) Measuring capillary blood glucose level for five clients E) Identifying nursing diagnoses after analyzing collected data

B, D

Which action would the nurse take first for a client complaining of headaches with a BP of 172/114? A) Page the on-call HCP and continue to monitor the BP B) Administer ibuprofen and have the client rest quietly for 20 minutes C) Elevate the head of the bed, provide reassurance, and reassess the BP D) Place the client in the supine position, administer O2, and notify the HCP

C) Elevate the head of the bed, provide reassurance, and reassess the BP

Which action would the nurse perform first when prioritizing care for a hypertensive client? A) Administer O2 B) Monitor BP C) Assess for severe headache D) Place the client in a semi-Fowler position

C) Assess for severe headache

Which nursing action is the priority when providing care to a trauma client? A) Monitoring VS B) Maintaining vascular access C) Assessing respiratory effort D) Evaluating LOC

C) Assessing respiratory effort

Which activity is an expectation of a primary nurse? A) Identify associate nurses B) Provide all direct client care C) Coordinate all aspects of a client's care D) Report the client's status to the charge nurse

C) Coordinate all aspects of a client's care

A group of nurse managers are reviewing a new job description for a staff nurse on a medical-surgical unit. Which observation if found would indicate that the job description needs revision with regard to delegation? A) Delineation of roles and responsibilities B) A listing of tasks that the nurse can complete C) No mention of the nursing position authority D) Listing of minimum qualifications for the nursing position

C) No mention of the nursing position authority

Which client condition would require the highest priority for treatment among four clients admitted at the same time under mass casualty conditions? A) Massive head trauma B) Open fracture with a distal pulse C) Shock D) Strains and contusions

C) Shock

Which intervention would the nurse perform first for a clinic client reporting a productive cough with copious yellow sputum, fever, and chills for the past 2 days? A) Encourage fluids B) Administer O2 C) Take the temperature D) Collect a sputum specimen

C) Take the temperature

A registered nurse (RN) delegated specimen collection to an unlicensed assistive personnel (UAP) for a patient who had a urine analysis ordered by the physician. The UAP did not obtain the specimen. When checking the patient's chart later in the shift, the RN noticed that there was no documentation that a urine specimen was collected. The RN asked the UAP to provide an explanation for why the specimen was not obtained. The UAP told the RN that she was going to obtain the specimen from the patient after lunch. Which stated action would correlate with the delegation right of right communication? A) The RN followed up later in the shift checking the patient's chart for documentation of the specimen collection B) The RN delegate the task to the UAP C) The UAP told the RN that she was going to obtain the specimen from the patient after lunch D) The RN monitored the task completion process

C) The UAP told the RN that she was going to obtain the specimen from the patient after lunch

Which task should not be delegated to an LVN by an RN who is working with an LVN and a UAP as part of the team? A) Performing oral hygiene for a patient who has oral ulcerations B) Feeding a patient with dysphagia C) Transferring a patient from the bed to a chair D) Monitoring a blood transfusion

C) Transferring a patient from the bed to a chair

Which care issues are priorities during chemotherapy? SATA> A) Resources available for the nurse B) Handling the chemo medications C) Managing the client's complications D) Protecting the client from side effects E) Treatment areas in which to serve clients

C, D

Which interventions are priorities to be followed in the critical rescue of clients with snakebites? SATA. A) Incise the wound B) Apply ice on the wound C) Encourage the client to rest D) Move the client to a safe area E) Remove the clothing and jewelry

C, D, E

Which nursing action is the priority action to ensure a client's safety when assisting a client out of bed? A) Monitoring the client's BP B) Assessing the client's LOC C) Ensuring the call bell is within the client's reach D) Assisting the client from a supine to an upright position

D) Assisting the client from a supine to an upright position

Applying the emergency severity index (ESI) criteria, which client condition is considered least severe? A) Cardiac arrest B) Abdominal pain C) Multiple traumas D) Closed extremity trauma

D) Closed extremity trauma

Which client assessment is triaged to non-urgent status by the ED nurse? A) Older adult male with purulent sputum B) Toddler with periods of unresponsiveness C) Middle-aged female with right scapular pain D) Teenager with ecchymosis and edema to the ankle

D) Teenager with ecchymosis and edema to the ankle

Which observation if made by an RN who is working with an LPN and a UAP would require immediate intervention based on the delegation process? A) UAP was transferring a patient out of bed who was 2 days postoperative laparoscopic surgery B) LPN was administering oral pain medication following performing a pain assessment C) LPN was monitoring a blood transfusion D) UAP was providing information to a patient who was just placed on isolation relative to neutropenic precautions

D) UAP was providing information to a patient who was just placed on isolation relative to neutropenic precautions

In which order would the nurse provide care for a client injured with frostbite? Place all options in the correct order. A) Assessing for the development of compartment syndrome B) Rewarming in a water bath at a temperature of 106°F C) Elevating the injured areas above the heart level D) Observing for signs of frostbite and preventing further tissue damage

D, B, C, A

Which primary nursing interventions would the nurse perform to check the circulation in a client? SATA. A) Prepare for chest decompression B) Evaluate LOC C) Prepare for endotracheal intubation D) Monitor VS, especially the pulse E) Maintain vascular access with a large-bore catheter

D, E

Prioritization

Deciding which patient needs or problems require immediate action and which are not urgent and can be addressed at a later time

UAP Scope of Practice

Includes activities of daily living, hygiene, and personal care

LPN Scope of Practice

Includes physical care, taking vital signs, administering medication, can vary from state to state

Team Nursing

Licensed and unlicensed personnel collaborate to deliver total care for a group of patients under the direction of a team leader

Overdelegation

Occurs when the workload is more than the delegate can accomplish in the allotted time frame

Total Patient Care

Often used in settings such as critical care and hospice care, the nurse provides holistic care. When used in the hospital setting, total patient care is provided by one nurse during a shift, communication is hierarchal, and the charge nurse is responsible for making assignments, interfacing with physicians, and shift reports

Right Task

One that can be safely delegated to a specific delegate for a specific patient

Staffing Mix

Refers to the appropriate numbers of RNs, LPNs/LVNs, and UAPs needed on a unit, is based on the type of care required for specific patients, and who is qualified to provide such care

Units of Service (UOS)

Reflect the basic measure of nursing workload based on different types of patient encounters

Patient Acuity

Represents how patients are categorized according to an assessment of their nursing care needs

Unit Intensity

Takes into account the totality of the patients for whom care is provided and the responsibilities of nursing staff

Delegator

The RN who is delegating the task

Delegation

The act of transferring to a competent individual the authority to perform a selected nursing task in a selected situation

Productive Time

The actual hours worked on the unit caring for patients

Nursing Judgment

The educated, informed, and experienced process that a nurse uses to form an opinion and reach a clinical decision based on the analysis of available information

Delegate

The person to whom the task is being delegated

Supervision

The provision of guidance or direction, oversight, evaluation and follow-up by the licensed nurse for accomplishment of a delegated nursing task by assistive personnel

Nursing Case Management

To organize patient care according to major diagnostic-related groups to achieve measurable quality outcomes while meeting predetermined time frames and costs

Care Delivery Models

Used to organize and deliver nursing care and focus on structure, process, and outcomes

Right Circumstance

When delegating, the nurse must consider the patient setting, available resources, and other relevant factors