Professional identity mastery
Which documentation is most informative for an assessment of drainage on a surgical dressing?
"A 10mm-diameter area of drainage at 1900." Rationale: this is objective data and it gives specific details regarding the assessment and a time frame. By providing size, it establishes parameters to compare with previous assessments and to further evaluate the drainage .
The registered nurse teaches a group of new nurses about leadership principles. Which statement made by a new nurse indicates a need for further teaching?
"A leader has a formal position" Rationale: a leader does not necessarily have a formal position to indicate they are a leader; lather, leadership refers to performance.
After signing a legal consent for hip replacement surgery and writhing hours before the surgery, the client states, "i decided not to go through with the surgery." Which response would the nurse use initially?
"Let's talk about your concerns regarding the procedure."
During a health symposium the nurse teaches the group how to prevent food poisoning. Which statement by one of the participants indicates the teaching is understood?
"Meats and cream-based foods need to be refrigerated" Rationale: a cold environment limits growth of microorganisms. All food should be refrigerates before and after it is cooked to limit the growth of microorganisms.
Which response would the nurse provide to a client who expresses malignancy fears associated with the pending bone biopsy report?
'It is very upsetting to have to wait for a biopsy report'
Which care settings are more suitable for unlicensed assistive personnel (UAP). Select all that apply.
A. Acute care B. Surgical care C. Extended care D. Long-term care E. Emergency care Long term care and extended care facilities
Which ethical principles govern the nurse's behavior when making difficult decisions about a client's care at the point of care?
A. Bioethics B. Metaethics C. Clinical ethics D. Research ethics C. Clinical ethics. Rationale: clinical ethics help in decision-making in issues that involve bedside client care and other client-related issues.
Which member of the health care team is responsible for analyzing the knowledge and skills of unlicensed assistive personnel (UAP) before delegating a task?
A. Charge nurse B. Associate nurse C. Registered nurse D. Nursing manager C. Registered nurse Rationale: the registered nurse must analyze any individual's knowledge and skills before delegating a task.
During the delegation process, which healthcare professional acts as a liaison between the team leader and healthcare provider?
A. Charge nurse B. Nurse Manager C. Nursing Supervisor D. Chief nursing officer A. Charge nurse Rationale: the charge nurse is responsible for acting as a liaison between the team leader and health care providers. The nurse manager is often responsible for more than one unit and has other managerial responsibilities The nursing supervisor will be delegated to supervise and ensure effective outcomes for the tasks delegated to the delegatees. The chief nursing officer is responsible for establishing the systems for assessment.
Which primary goal can be achieved with delegation?
A. Delivering client care as a team B. Maximizing client care outcomes C. Improving the working ability of the nurse D. Maintaining open lines of communication between delegator and delegatee B. Maximizing client care outcomes Rationale: the ultimate goal of the delegation is to maximize client care outcomes.
Which potential effect will the nurse teach to a client receiving metoprolol?
A. Dizziness with strenuous activity B. Acceleration of the heart rate after eating a heavy meal C. Flushing sensations after take the medication. D. Pounding of the heart A. Dizziness with strenuous activity Rationale: Because metoprolol competes with catecholamines at beta-adrenergic receptor sites, the expected increase in the heart's rate and contractility in response to exercise does not occur. This, combined with the medication's hypotension effect, may lead to dizziness. Metoprolol decreases the heart rate.
Which external barriers can prevent a nursing professional from making morally correct actions? Select all that apply.
A. Inadequate staffing B. Lack of assertiveness C. Perception of powerlessness D. Lack of organizational support E. Poor relationships with colleagues A, D, and E Rationale: when faced with dilemmas, external and internal barriers may prevent a professional from acting in a morally correct way. This may cause moral distress. External barriers are factors present in the organizational environment.
The registered nurse is evaluating the statements made by a student nurse after teaching ways to make appropriate delegation decisions. Which statement made by the student nurse indicates a need for correction?
A. The delegatee would report the findings back to the delegator B. The delegatee would understand the assigned task completely C. The delegator would trust the delegatee to accomplish the task D. The delegator would recheck and redo the work of the delegatee D. The delegator would recheck and redo the work of the delegatee Rationale: time management is an important part of an appropriate delegation process. If the delegator rechecks and redoes the work of the delegatee, it increases the time to accomplish the ask and results in inappropriate delegation.
Which information will the nurse share about slope is characteristics to a client who is to receive chemotherapy after surgery for cancer>
A. Usually rare B. Not permanent C. Frequently prolonged D. Usually preventable B. Not permanent Rationale: Once the medications that interfere with cell division are stopped, the hair will grow back; sometimes the hair will be a different color or texture. Slope is is a common side effect of chemotherapy. Hair loss persists while the medications are being received; once the medications are withdrawn, the hair grows back.
Which generation of nursing professionals, being exposed to both terrorism and natural disasters, would be key members for disaster planning initiatives?
A. Veteran B. Generation X C. Generation Y D. Baby Boomer C. Generation Y Rationale: Generation Y nurse are the future of the profession and have grown up with massive amounts of information and technology. They have experiences terrorism and natural disasters. This generation of nurses would be key members for disaster planning initiatives.
When performing a physical assessment on a client, which term would the nurse use to describe a flat, poorly defined mass on the sole over a bony prominence and caused by pressure?
Callus
The nurse is helping a client and the family to set and meet goals. Which professional role is the nurse displaying?
Caregiver Rationale: as a caregiver, the nurse helped the client and the family set goals. The nurse also assists them in meeting these goals with a minimal financial cost, time, and energy.
Multilevel nursing model
Consists of RNs, licensed practical nurses, and unlicensed assistive personnel
In a community based practice, which competency would the nurse utilize when helping a client identify and clarify personal health problems to choose appropriate courses of action?
Counselor
When teaching the staff about how the health care provider strives to work effectively within the cultural context of a client, which cultural principle is the nurse leader explaining?
Cultural competence Rational: cultural competence is the process in which the health care provider strives to achieve the ability to work effectively within the cultural context of a client, individual, family, or community.
Which process involves transferring responsibility to multiple individuals, usually with varying degrees of education and experience, while retaining the ultimate accountability for providing the client care?
Delegation Rationale: delegation is a process of sharing the responsibility of client care. It involves the transfer of responsibility for the performance of an activity from one individual to another, with he delegator retaining accountability for the outcome.
Which statement reflects the role of a case manager?
Demonstrates and ability to establish an appropriate plan of care based on the assessment of clients and families
As a leader, which role would the nurse executive fulfill
Empowerment
Nurse Practice Act
Examines the value of licensed and unlicensed personnel in client care delivery and declares that the importance of delegation decisions is the safety and welfare of the public
How many rights of delegation in nursing practice are there?
Five There are 5 rights of delegation in nursing practice, they are right task, right circumstances, right person, right direction/communication, and right supervision/evaluation
Which training will help nurses identify signs of biological terrorism?
Hazardous Materials (HAZMAT)
change agent
Helps identify and implement new approaches and increased efficient for solving problems.
Which mechanism of action explains how hydrochlorothiazide increases urine output?
Increases the excretion of sodium
Which statement refers to the accountability element of the decision-making process?
Individuals being answerable for their actions
A client is schedules for a cholecystectomy and asks the primary nurse about he function of the gallbladder. Which explanation would the nurse give?
It stores and concentrates bile Rationale: the gallbladder concentrates and stores about 90mL of bile, which is discharged in response to the entrance of fatty food into the duodenum. The gallbladder releases bile into the cystic duct. The common bile duct is connected directly to the pancreas. The sphincter of Oddi controls the release of bile into the duodenum; dietary fat progresses from the stomach to the duodenum and then to the rest of the intestinal tract.
Which rule or responsibility would the nurse leader fulfill when setting priorities for achieving success by using the simplest and fastest method of communication?
Maintaining balance. Rationale: an effective leader maintains work-life balance in his or her own life, as well as facilitating balance for followers. Making communication as efficient as possible is one way of helping maintain this balance
Benner's Stages of Clinical competence, low to high
Novice, Advanced beginner, competent, proficient, expert
Which characteristic indicates that nursing is a profession?
Nurses are required to follow a code of ethics Rationale: nursing is a profession because it follows a code of ethics, in which philosophical ideals of right and wrong defines the principles the nurse used to care for the clients. Nursing is not just a collection of specifics skills performed by a trained individual. The nurse is expected to act professionally by administering quality client-centered care in a safe, conscientious, and knowledgeable manner.
When examining a health care origami action under the rubric of The Magnet Recognition Program's 14 forces of magnetism, the nurse would review the structural empowerment of the organization for which force of magnetism?
Personnel policies and programs
Which responsibility of the nurse manager differs from the responsibilities of the nurse leader?
Planning the budget
To be effective, which characteristic would be important for a nurse leader?
Problem-solving skills
Which action of the emergency department nurse caring for a group of clients injured in a community disaster would need correction?
Removing people from danger Rationale: during a community disaster, removing people from danger is done by firefighters and other disaster trained emergency personnel.
Which strategy regarding the quality improvement (QI) process requires the nurse manager's revision?
The focus is on correcting errors
Which model of nursing focuses on the task-oriented approach to client care?
The functional model
Which role task would the nurse leader carry out as a member of the human resource team?
The nurse stays clear on group outcomes Rationale: when the nurse participates as a leader in any leadership opportunities such as on human resource teams, this role indicates they are staying clear on group outcomes.
Delegation
The transfer of authority to perform some type of task or work
Which behavior would the nurse consider suitable for an executive position according to gardner's tasks of leading/managing
To assist corporate leaders with planning and priority setting Rationale: according to gardner's tasks of leading/managing, a behavior of the executive position is to assist corporate leaders with planning and priority setting.
Which responsibility did the federal government assign to the professional standards review organizations (PSROs)?
To review quality, quantity, and cost of hospital care
Which internal factor affects the decision-making process of a leader? Select all that apply
Values, interest, knowledge
The nursing manager wants to transfer a nurse to the intensive care unit (ICU) and describes the roles and responsibilities of the position in detail to the nurse. After disclosing all details, the nurse manager inquires about the nurse's decision. Which type of principle is the nurse manager following?
Veracity. Rationale: veracity means disclosing all the facts of a situation truthfully, and then assisting employees to make appropriate decisions.
Which role is the most important for the nurse to assume when providing therapeutic crisis intervention?
active participant
Which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choosing care strategies for clients?
explanation Explanation requires knowledge and experience for choosing strategies for care of clients. Analysis is a critical thinking skill that requires open-mindedness while looking at the client's information. The skill of inference is associated with noticing relationships in the findings. Interpretation is associated with an ordered data collection.
counselor
helps patients identify and clarify health problems and choose appropriate courses of action to solve those problems
Which nurse collaborates with the client to establish and implement a basic plan of care on admission?
primary nurse Rationale: the primary nurse provides or oversees all aspects of care, including assessment, implementation, and evaluation of that care.
Which model of ethics considers broad social issues and involves accountability to the overall institution?
social justice model
Which member of the health care team is accountable for initial assessment and ongoing evaluation of client care?
A. Registered nurse B. LPN C. Primary health care provider D. UAP A. Registered nurse
Which entity outlines the principles of delegation for registered nurses (RN)?
American Nurses Association (ANA)
Followership
Each member of a team contributes optimally but acquiesces to a lesser or manager to ensure the best clinical decision-making.
The World Health Organization (WHO)
Focuses on global issues
Leadership
The use of individual traits and abilities in a relationship to others and the ability to interpret the context where a situation is emerging
In which role does the nurse oversee the budget of a specific nursing unit or agency?
nurse manager
Which response by the nurse is therapeutic when a male client with ascites is to have a paracentesis and has signed consent but, while the nurse is caring for him, he says that he has changed his mind and no longer wants the procedure?
A. "Why did you sign the consent?" B. "Tell me why you want to refuse the procedure" C. "You are obviously afraid about something concerning the procedure" D. "Although the procedure is very important, I understand why you changed your mind" B."Tell me why you want to refuse the procedure" Rationale: The response is open ended and attempts to explore why the client is refusing the procedure; it promotes communication.
A client with asthma and depression is admitted to the hospital. Which tasks delegated by the delegator would be completed by the registered nurse?
A. Administer oral antidepressants B. Administer a pain killer intramuscularly C. Teach the client how to use a metered-dose inhaler D. Reinforce tips for stress management with the client C. Teach the client how to use a metered-dose inhaler Rationale: the registered nurse is delegated to teach the client about using a metered-dose inhaler for asthma.
Which action would a nurse take to prevent a parallax error and to ensure accuracy when assessing a client's blood pressure?
A. Elevate HOB B. Use the appropriate-sized cuff C. Read the manometer at eye level D. Place the cuff at the level of the heart C. Read the manometer at eye level Rationale: a parallax error is the apparent displacement of an observed object, such as the indicators on the manometer, because of the position of the observer.
Which phrase describes the meaning of the term in-service education?
A. Helps the nurse achieve an organization's required competencies B. Helps the nurse gain knowledge about traditional health care practices C. A one-way education program to promote and maintain current nursing skills D. Focuses on techniques and technologies that have been used successfully in the past, A. Helps the nurse achieve an organization's required competencies Rationale: In-service education helped the nurse achieve an organization's required competencies. Continuing education and in-service education help the nurse gain knowledge about the latest research and practice developments.
Appropriate delegation in a health care organization achieves which outcomes? Select all that apply
A. Reduces stress B. Decreases trust C. Reduces client care D. Decreases time efficiency E. Improves treatment outcomes A & E Rationale: Delegation requires empowerment of the delegatee to accomplish the task, and sharing functions reduces stress. As functions are distributed, treatment outcomes improve.
Which quality is the most important tool the nurse brings to the therapeutic nurse-client relationship?
The self and a desire to help Rationale: the nurse brings an understanding of self and basic principles of therapeutic communication; this is the unique aspect of the helping relationship.
Which description is correct in defining 'accountability'
A. Accomplishment of the task and fulfilling the requirements B. Provision of guidance and oversight of a delegated nursing task C. Obligation to accomplish work with reliability and dependability C. Determination of appropriate actions and providing detailed explanations of the actions C. Determination of appropriate actions and providing detailed explanations of the actions Rationale: ACCOUNTABILITY is the expectation that actions performed are appropriate, and that a detailed explanation of what occurred is provided. AUTHORITY- the ability to perform duties in a specific role, such as accomplishment of the task and fulfillment of the expected outcomes SUPERVISION- provision of guidance and oversight of a delegated nursing task RESPONSIBILITY- is reliability, dependability, and the obligation to accomplish work
In providing effective nursing care for clients from different cultural backgrounds, which strategy would the nurse follow?
A. Advise clients that some cultural practices may be harmful to health. B. Provide care that fits the client's cultural beliefs. C. Strictly adhere to organization policies regarding nursing care. D. Ignore the cultural aspect and focus on the medical aspect of care B. Provide care that fits the client's cultural beliefs Rationale: when providing care to clients from different cultural backgrounds, nurses would be careful to provide care that first the client's cultural beliefs.
Which legal defense is important for the nurse to develop?
A. Dedication B. Certification C. Assertiveness D. Accountability D. Accountability Rationale: the concept of accountability is of high priority in nursing practice. As a licensed professional, the nurse is always accountable, which means liable and answerable for actions.
The nurse on the medical-surgical unit tells other staff members, 'That client can just wait for the lorazepam; i get so annoyed when people drink too much.' Which does this nurse's comment reflect?
A. Demonstration of personal bias B. Problem-solving based on assessment C. Determination of client acuity to set priorities D. Consideration of the complexity of client care A. Demonstration of a personal bias. Rationale: When nurses make judge mental remarks and client needs are not placed first, the standards of care are violated and quality of care is compromised. Assessments would be objective, not subjective and biased.
When informing the health care provider of a client requesting pain mediation after surgery, which role did the nurse play?
A. Educator B. Manager C. Advocate D. Administrator C. Advocate Rationale: nurse acts as a client advocate by speaking to the primary health care provider on behalf of the client.
Which function is part of Hersey's 2006 model related to delegation?
A. Five rights of delegation B. Legal authorities for delegation C. Characteristics of communication D. Core competencies of a situational leader D. Core competencies of a situational leader Rationale: Heresy's model describes situational leadership, which includes the core competencies of a situational leader. Anthony and Vidal describe the five rights of delegation Heresy's model does not include legal authorities for delegation Anthony and Vidal described characteristics of communication such as information decay and information salience.
At which point would the nurse start to discuss terminating the nurse-client relationship with a client?
A. Working phase, when the client initiates it B. Orientation phase, when a contract is established C. Working phase, when the client shows some progress D. Termination phase, when discharge plans are being made B. Orientation phase. Rationale: when the nurse and client agree to work together, a contract should be established and the length of the relationship should be discussed in terms of the eventual termination.
Which action would the nurse leader take when preparing to share information with followers?
Determining which information is to be shared
In which order would the nurse arrange the human needs of maslow's hierarchy? Arrange from the top priority need to the lowest priority need
Physiological, safety, social, esteem, and self-actualization
As a part of informed consent, a surgeon explains to the client who is scheduled for surgery the details of the surgery and the related care. The nurse as a leader witnesses the complete procedure. What information does the nurse leader ensure was provided to the client? Select all that apply.
Surgical procedure Name of surgeon Explanation of possible risks Informed consent must be done according to legal guidelines. It is an authorization by the client to perform a surgery or procedure on them.
While auditing unit documents, a nurse finds some omissions. Which term best describes when the nurse meets with the staff to discuss the findings and communicates ways to achieve the desired goals?
management Rationale: the process of guiding, planning, and controlling others in a situation in which communication is shared to improve clinical processes and outcomes is referred to as management
Which interventions are in the scope of a licensed practical nurse (LPN)? Select all that apply
A. Client teaching B. Ambulating the client C. Interpreting laboratory data D. Assisting the client with bathing E. Administering intramuscular medications B, D, and E
The health care team is caring for a client who has undergone surgery for lung cancer. The client needs respiratory therapy. Which task can be safely delegated to a respiratory therapist paired with a registered nurse (RN)?
A. Placing a foley Catheter B. Assessing the respirations C. Placing an intravenous (IV) catheter D. Administering patient-controlled analgesia B. Assessing respirations Rationale: respiratory therapy is needed in clients who undergo surgery for lung cancer. Assessing respirations can be safely delegated to the respiratory therapist.
Which term refers to a nurse's ability to plan, direct, control, and evaluate others in different situations?
Management Rationale: management is defined as the ability to plan, direct, control, and evaluate the nursing staff in nations situations
A nurse who promotes freedom of choice for clients in decision-making best supports which principle?
A. Justice B. Autonomy C. Beneficence D. Paternalism B. Autonomy Rationale: the principle of autonomy relates to the freedom of a person to form their own judgements and actions. The nurse promotes autonomy nonjudgementally so as not to infringe on the decisions or actions of others.
Which action would the nurse take when the client still has moderate to severe anxiety after the health care provider has explained the schedules head and neck surgery?
Attempt to discover the client's concerns. Rationale: various aspects of hospitalization and diagnosis may cause the client to become anxious. The nurse would identify what concerns the client most.
Which role would the nurse demonstrate when questioning staff about a change in the client's plan of care?
Authority
Which would be the nurse consider to be the center of decision-making when providing client care?
A. Ethics B. Nursing Skills C. Analytic skills D. Research-based practice. A. Ethics Rationale: a professional nurse always follows the ethics of care and considers caring to be the center of decision-making. The nurse must know what behavior is ethically appropriate while caring for a client.
A client with internal bleeding is in the intensive care unit (ICU) for observation. At the change of shift an alarm sounds, indicating a decrease in blood pressure. Which action should the nurse take?
A. Perform an assessment of the client before resuming the change-of-shift report B. Continue the change-of-shift report and include the decrease in blood pressure C. Lower the diastolic pressure limits on the monitor during the change-of-shift report. D. Turn off the alarm temporarily and alert the oncoming nurse to the decrease in blood pressure A. Perform an assessment of the client before resuming the change-of-shift report Rationale: The cause of the alarm should be investigated, and appropriate intervention instituted. After the client's needs are met, then other tasks can be performed.
When auscultation a client's chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this finding?
A. Adventitious sounds B. Fine crackling sounds C. Vesicular breath sounds D. Diminished breath sounds C. Vesicular breath sounds. Rationale: Vesicular breath sounds are normal respiratory sounds heard on auscultation as inspired air enters and leaves the alveoli. 'Adventitious' is the general term for all abnormal breath sounds. Crackles heard at the end of an inspiration are associated with fluid in the alveoli. Diminished breath sounds are evidence of a reduction in the amount of air entering the alveoli; this usually is caused by obstruction or consolidation
Which professional strategy is most effective for nurse leaders and managers to implement in improving safety and quality of client-centered care?
A. Autonomy B. Guidance C. Delegation D. Accountability C. Delegation Rationale: delegation is the most effective strategy for nurse leaders and i managers to implement to improve safety and quality of client-centered care. Delegation requires knowing the level of competence of the individual delegatee and understanding the concepts of responsibility, authority, and accountability.
Which statement made by the nurse requires correction when discussing registered nurse licensure in the United States with peers?
A. Candidates must pass the NCLEX-RN exam to become licensed in their state B. The scope of practice for registered nurses is found in each state's Nurse Practice Act C. The examination for RN licensure is exactly the same in every state in the United States D. Passing the NCLEX-RN examination indicates maximal knowledge base for safe nursing practice D. Passing the NCLEX-RN examination indicates maximal knowledge base for safe nursing practice Rationale: passing the NCLEX-RN exam means the candidate possesses the MINIMUM knowledge base for nurses to practice safely.
How can the nurse evaluate the effectiveness of communication with a client?
A. Client feedback B. Medical assessments C. Health care team conferences D. Client's physiological responses A. Client feedback Rationale: feedback permits the client to ask questions and express feelings and allows the nurse to verify client understanding.
Which statement is true regarding delegation? Select all that apply.
A. Delegatees are accountable for effective client care. B. Open lines of communication must occur between delegator and delegatee C. Delegation occurs only when at least 2 people are involved in a mutual work situation D. Delegation potentials are significantly lower when caregivers such as UAP's are partnered. E. Delegation involves sharing activities with other appropriate authorities to accomplish the work B, C, AND E.
Which role does the nurse play when helping clients identify and clarify health problems and choose appropriate coursed of action to solve those problems?
A. Educator B. Counselor C. Change agent D. Case manager B. Counselor Rationale: as a counselor, the nurse helps clients identify and clarify health problems and choose appropriate courses of action to solve those problems.
Which role is the nurse fulfilling when explaining the reason for the intravenous infusion and kit to the client?
A. Educator B. Manager C. Advocate D. Caregiver A. Educator Rationale: the nurse assumes the role of educator when explaining to the client the need for an intravenous infusion. The nurse manager oversees the budget of a nursing unit or agency and is responsible for coordinating activities. Nurse as an advocate protects the human and legal rights of the client The nurse as a caregiver is helping the client maintain and regain health, manage disease symptoms, and achieve a maximum level of functioning.
Which failure is consistent with an improper follow-through on the part of the delegatee?
A. Failure to report results and findings B. Failure to understand the skills and abilities C. Failure to provide clear and concise directions D. Failure to cooperate with the other team members A. Failure to report the results and findings B. Failure to understand the skills and abilities C. Failure to provide clear and concise directions D. Failure to cooperate with the other team members. A. Failure to report the results and findings Rationale: improper follow-through on the part of a delegate is failure to report results and findings.
A client is discussing with the nurse concerns about their unhealthy family relationships. During the nurse-client interaction the client begins to talk also about a job problem. The nurse's response is 'let's go back to what we were just talking about.' Which therapeutic communication technique did the nurse use?
A. Focusing B. Restating C. Exploring D. Accepting A. Focusing Rationale: focusing is a technique that directs a client back to the original topic of discussion. Restating the main idea of what the client has said encourages the client to continue to continue speaking or clarifies what has been said.
The RN is caring for an older client who has been admitted to the hospital. The RN allocated several tasks to the UAP. To evaluate the understanding of the UAP, the RN asks the UAP to describe which tasks have been allocated. Which responses by the UAP indicate effective understanding of the tasks? Select all that apply
A. I must assist the client with oral care B. I must assess the client's health status C. I must administer intravenous medication in accordance with the schedule D. I must give a sponge bath to the client every morning E. I must record the blood pressure of the client at regular intervals. A, D, and E Rationale: the RN allocates tasks to the UAP based on the capabilities and skills of the UAP. The UAP can perform tasks that involve basic hygiene and activities of daily living, such as oral care, toileting, bathing, and eating. The UAP can also perform tasks involving vital signs such as blood pressure readings and temperature measurement.
Which questions would the delegator assess to determine the RIGHT TASK? Select all that apply
A. Is the task legally appropriate to delegate? B. Is the environment conducive to completing the task safely? C. Does the delegator provide clear and concise directions for the task? D. Is the task appropriate to delegate based on institutional policies and procedures> E. Does the delegatee have the knowledge and experience to perform the specific task safely? A & D Rationale: the delegator has to determine the RIGHT TASK by assessing whether the task is legally appropriate to delegate. The delegator must also check that the task is appropriate to delegate based on institutional policies and procedures. B is the RIGHT CIRCUMSTANCE C is the RIGHT DIRECTION & COMMUNICATION. E. Is the RIGHT PERSON
Which characteristic would the nurse use during the nursing process as a guide for delegation?
A. Leadership B. Critical analysis C. Psychomotor task D. Time management B. Critical analysis Rationale: critical analysis by the registered nurse serves as a guide for delegation in the nursing process. It is applies in assessment, planning, implementation, and evaluation for safe and effective client care. Leadership is a role in which the nurse has charge of the personnel as they perform their tasks. Psychomotor tasks are the common characteristics and essential components that the nurse should possess to provide client care. Time management is essential in performing tasks within specified deadlines during delegation
Which statement indicates that the nurse is in the advanced beginner stage of Benner?
A. Learns about the profession through a specific set of rules and procedures B. Identifies the basic principles of nursing care through careful observation C. Understands the organization and specific care required by certain clients D. Assesses the entire situation and transfers knowledge gained from multiple previous experiences B. Identifies the basic principles of nursing care through careful observation Rationale: according to the levels of proficiency set forth by Benner, the nurse in the advanced beginner stage is able to identify basic principles of nursing care through careful observation. Novice stage learns about the profession through a specific set of rules and procedures. Competent stage- able to understand the organization and specific care required by certain clients Proficient stage- able to assess an entire situation and transfer knowledge gained from multiple previous experiences.
Which task can be delegated to a cross-trained technician when paired with a registered nurse?
A. Monitoring vital signs B. Drawing blood samples C. Teaching clients directly D.administering intravenous medication B. Drawing blood samples Rationale: drawing the blood samples, or phlebotomy, can be delegated to cross-trained technicians when paired with he RN. The cross-trained technician can only record vital signs; monitoring the VS is outside of the scope of practice of a cross-trained technician
Which health care team member is most suitable to provide oral medication to a client?
A. Nurse Manager B. Client care associate C. Licensed practical nurse (LPN) D. Unlicensed assistive personnel (UAP) C. LPN Rationale: activities such as providing oral medication to the client is the responsibility of the LPN Nurse manager: mainly involved in delegating tasks and managing other emergency conditions Client care associates and UAP: unlicensed practitioners who are primarily responsible for providing hygienic care to clients.
Which is the most independently functioning nurse?
A. Nurse educator B. Nurse researcher C. Nurse administrator D. Advanced practice registered nurse. D. Advanced practice RN Rationale: the advanced practice registered nurse is the most independently functioning nurse. The nurse educator, nurse researcher, and nurse administrator must all be associated with an organization to pursue their professional prospects.
Which nursing professional has the maximum span of control?
A. Nurse manager B. Registered nurse C. Unlicensed assistive personnel D. Licensed vocational nurse A. Nurse manager Rationale: Span of control, the number of people for whom one is ultimately responsible, increases with the number of individuals under a person's control. The nurse manager is the person responsible for the tasks performed by registered nurses, unlicensed assistive personnel, licensed vocational nurses/ licensed practical nurses, and other nursing professionals.
For the intensive care of cancer clients, for which employment position would the facility hire a nurse?
A. Nurse practitioner B. Nurse administrator C. Certified-midwife D. Clinical nurse specialist D. Clinical nurse specialist Rationale: The hospital will likely hire a clinical nurse specialist. The clinical nurse specialist is an expert in a specific are of practice in a particular setting, such as an intensive care unit. NP- expertise in taking care of clients in an outpatient, ambulatory care, or community care setting. Nurse administrator- manages the care provided to clients within a health care agency Certified nurse-midwife- provides care to women during their pregnancy, labor, or delivery
Which component of the nursing process includes tasks that can be delegated?
A. Planning B. Evaluation C. Assessment D. Implementation D. Implementation Rationale: implementation of certain tasks can be delegated by the registered nurse (RN) based on the ability and willingness of the delegatee. The pervasive functions of assessment, planning, evaluation, and nursing judgement cannot be delegated by the RN. These nursing processes should be performed by the RN only.
Which action would the nurse take for an adolescent with a long history of drug abuse, stealing, and refusal to comply with rules?
A. Provide activities that ensure immediate gratification and social stimulation B. Allow as much freedom as possible, setting few rules and minimal structure C. Serve as a role model for mature behavior while providing a structured setting D. Behave in a punitive manner toward the adolescent when rules are not followed C. Serve as a role model for mature behavior while providing a structured setting. Rationale: The client is unable to control impulses at this time, so control must be provided for the client; the nurses behavior provides a role model.
Which action would the nurse take for a client with borderline personality disorder?
A. Provide an unstructured environment to promote self-expression B. Be firm, consistent, and understanding while focusing on specific target behaviors. C. Use an authoritarian approach, because this type of client needs to learn to conform to the rules of society D. Record but ignore marked shifts in mood, suicidal threats, and temper displays because there are attention-seeking behaviors. B. The nurse would be firm,consistent, and understanding while focusing on specific target behaviors. Consistency, limit-setting, and supportive confrontation are essential nursing interventions designed to provide a secure, therapeutic environment for clients with BPD.
The nurse working in a Catholic hospital discourages clients from using contraceptives per hospital policy. Which category of ethics is the nurse following?
A. Societal ethics B. Research ethics C. Professional ethics D. Organizational ethics D. Organizational ethics Rationale: organizational ethics help ensure smooth ethical operation of an organization. These ethical codes include sets of rules and regulations to guide the actions and behavior of the members of the organization.
The registered nurse (RN) is caring for a client admitted with sudden paralysis of the legs and an inability to walk. Which intervention made by the RN indicates correct active delegation?
A. The RN assessing the client's diagnostic and laboratory findings B. The RN administering an intravenous (IV) calcium gluconate injection C. Instructing the licensed practical nurse (LPN) to report the client's vital signs D. Instructing the unlicensed assistive personnel (UAP) to administer oral vitamin D3 C. Instructing the licensed practical nurse (LPN) to report the client's vital signs Rationale: In active delegation, the RN assesses the situation, determines what is appropriate for client care, and directs nursing staff to perform certain tasks.
Which statement is true about the nursing model of team nursing?
A. The RN is responsible for all aspects of client care B. Client care can be delegated to other members of the health care team C. The RN works directly with he cleans, family members, and health care members D. Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members D. Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members
Which statement indicates the client with chronic kidney disease understands the purpose of using continuous ambulatory peritoneal dialysis (CAPD)?
A. The treatment provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration. B. The treatment exchanges and cleanses blood by correction of electrolytes and excretion of creatinine. C. The treatment decreases the need for immobility, because the fluids clear the toxins in short and intermittent periods. D. The treatment used the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion. D. The treatment uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion Rationale: diffusion moves particles from an area of greater concentration to an area of lesser concentration. Osmosis moves fluid from an area of lesser concentration to an area of greater concentration of particles, thereby removing waste products into the dialysate, which is then drained from the abdomen.
The nursing manager is preparing a schedule for delegating appropriate tasks to different health care team members. Which health care team member can be delegated the task of administering oral medications? Select all that apply. One, some, or all responses may be correct.
A. Unit secretary B. Social worker C. LPN D. LVN E. UAP C & D. LPN AND LVN. Rationale: delegation of tasks is different for different health care team members, based on their position, skills, and capabilities. Provision of prescribed treatments, such as administering oral medications, are tasks delegated to licensed professionals, such as LPNS and LVNS.
In which client situations does the process of delegation become more challenging? Select all that apply
A. When the client is stable B. When the client is pregnant C. When the geographical area is small D. When the resources are abundant E. When school children are receiving care B & E. Rationale: the delegation process becomes more challenging when vulnerable populations such as pregnant women and school children are receiving care.
caregiver
Applies a critical thinking approach to ensure appropriate, individualized nursing care for clients and their families
Which intervention can be performed by an unlicensed assistive personnel in skin care? Select all that apply
Assist the client in bathing, apply wet dressings to the skin, and report changes in the skin appearance. Rationale: the UAP may be responsible for assisting with bathing, applying wet dressings, and reporting changes in skin. Teaching done by the RN can be reinforced by an LPN or LVN. The RN would be responsible for determining whether the client is taking a medication that increases photosensitivity
Which feature, according to Benner, is observed in the nurse at the "proficient" level?
Focuses on managing care rather than managing skills. Rationale: the nurse at the proficient level has more than 2 or 3 years of experience in the same clinical position. The nurse focuses on managing care rather than managing and performing skills Novice nurse- learns by means of a set of rules Advanced beginner- has observational experience and is able to identify principles of nursing care Expert nurse- is skilled at identifying client-centered problems, health care system-related problems, and the needs of the novice nurse
