ADU Management of Care
during the admission interview of a client admitted for cardiac surger, the nurse inquires about the existence of advance directives, using the terms :living will" and "durable power of attorney for health care". The client becomes upset and shouts, " I do not need any advance directives. I already have a will and an attorney who helps me with everything. Besides, I am not going to die!" which response by the nurse is best?
" A regular will and attorney do not cover healthcare situations, including if you cannot, even temporarily, make you wishes known.
the medical nurse reviews charting principles with newly assigned LPNs/LVNs. Which of the following should the nurse indicate is charting that reflects subjective data?
"Patient states, "I have had pains in my stomach for three days now"
the charge nurse is having difficulty making an appropriate assignment for the nursing team. which assessment by the supervisor will help the charge nurse make the assignment for the day shift?
"describe the knowledge and skill level for each member of you team"
which of the following client statements about advance directives MOST concerns the nurse on the medical surgical unit?
"my living will is all made out and secure in my safe deposit box"
the nursing team consists of two RNs, two LPN/LVNs, and two nursing assistants. The nurse should consider the assignment appropriate if the LPN/LVN is required to complete which of the following tasks?
Administer a tube feeding for a patient with dysphagia
the community health nurse plans visits for the day. which of the following patients should the nurse see first?
a 13 year old female vomiting every day for the last three months because she wants to lose weight for the summer
the nurse is seeing patients in the psychiatric clinic. which of the following patient should the nurse see first?
a 15 year old male brought in by police because he threatened to jump off a bridge and has access to a gun
the nurse is seeing patients in the adolescent psychiatric clinic. which of the following patients should the nurse see first?
a 15 year old who wants to be a model and only drinks water and eats vegetables
after receiving the night shifts report, the nurse plans assignments for the day. which clients should the nurse see first?
a 17 year old who took 10 methylphenidate and has a blood pressure of 160-100
clients from a plane crash are transferred to the hospital. the nurse performs triage in the emergency department. which client should the nurse see first?
a 20 year old with burns to the chest and face area
four clients from a house fire and transferred to the emergency department (ED). Which client will the nurse see first?
a 20 year old with full thickness burns to the face and chest area
a psychiatric nurse is presented with a group of patients in the ER. Which of the following patients required IMMEDIATE attention?
a 24- year old male who failed medical school and says, "my pain will be over soon"
the nurse is seeing clients in the gastrointestinal clinic. which clients should the nurse see first?
a 3 week old infant experiencing projectile vomiting irritability
the nurse cares for clients in a gynecological clinic. Which of the following clients should the nurse see first?
a 35 year old female who had a hysterosalpingogram and is experiencing tachycardia and has a generalize rash
the pediatric community health nurse plans visits for the day. which client will the nurse see first?
a 6 year old with elevated temperature, cough, and fine crackles
children from a school bus accident are transferred to the hospital. the nurse triage in the emergency department (ED). which child should the nurse see first?
a 7 year old with burns on 10% of the total body surface area
after receiving the night shifts report, the nurse plans assignments for the day on the endocrinology unit. which client should the nurse see FIRST?
a 70 year old with a fasting blood glucose of 517 mg/dl
the community health nurse plans visits for the day. which clients will the nurse see first?
a 76 year old with a laryngectomy reporting a greenish yellow discharge.
the nurse is seeing clients in the pediatric clinic. which of the following clients should the nurse see first?
a 9 month old infant with failure to gain weight and a blood lead level of 70 mg/dl
the nurse is seeing patients in the pediatric clinic. Which of the following patients should the nurse see FIRST?
a 9 year old who has used a weapon against his mother and caused physical harm to other.s
an RN from the psychiatric unit is reassigned to the pediatric unit. which clients assignments is most appropriate for this nurse?
a child experiencing separation anxiety who wants to stay home with parent instead of going to school
the nursing team caring for clients on the pediatric unit consits of two RNs, two LPN/LVNs and two nursing assitive personnel. which client will the nurse assign to eh LPN/LVN?
a child in a balance suspension traction for a fractured left femur
the nursing team caring for clients on the pediatric unit consists of one RN, two LPN/LVNs, and three nursing personnel. which client should the nurse assign to a nursing assistive person?
a child who needs help socializing with other children
the nurse cares for clients in the child psychiatric clinic. which clients should the nurse see first?
a child with auditory hallucinations
the nursing team consists of an RN, two LPN/LVNs, and two nursing assistive personnel. it is most appropriate for the nurse to care for which client?
a client 24 hours after a laminectomy with spinal fusion having difficult voiding
An RN has received reports and assesses the clients on the unit. It is most important for the RN to assign which client to the LPN/LVN?
a client diagnosed with COPD who required ambulation twice during the evening.
An RN from the pediatric unit is assigned to the psychiatric unit. which client assignment is the most appropriate for the reassigned nurse?
a client diagnosed with depression with a decreased appetite
the nurse is seeing clients in the medical-surgical unit. which client will the nurse see first?
a client diagnosed with heart failure who received 800 mL of IV fluids in 2 hours
after receiving the night shift's report, the nurse plans assignments for the day on the pediatric unit. which client will the nurse see first?
a client diagnosed with hemophilia report joint pain
four clients in the ER are complaining of side effects from their medication. which of the following clients should the nurse see first?
a client receiving clozapine and experiencing flu-like symptoms
the nurse cares for clients in the psychiatric emergency department. which client will the nurse see first?
a client receiving haloperidol experiencing an oculogyric crisis
and RN receives the assignment of the day shift. Which clients is appropriate for the nurse to delegate to an LPN with 30 years of experience?
a client three days postoperative requiring a dressing change
ten clients from a motor vehicle accident are transferred to the hospital. The nurse triage's in the emergency department. Which client should the nurse see first?
a client with a blood pressure of 90/60 and apical pulse of 120 bpm
four injured firefighters are transferred to the hospital. the nurse performs triage in the emergency department. which client will the nurse see first?
a firefighter diagnosed with carbon monoxide poisoning
the community health maternity nurse plans visits for the day. which client should the nurse see FIRST?
a newborn with pallor
student nurses discuss characteristics of good documentation. The student nurses identify which of the following adheres to the legal guideline for appropriate documentation?
a nurse documents changes to the patients condition
the nurse collapses minutes after putting on latex gloves, and the cardiac team successfully resuscitates the nurse. The nurse manager discusses that certain workers may be at greater risk for latex allergies than others. after reviewing the medical histories of the nurses on the unit, the nurse manager determines which of the following nurses can safely use latex products?
a nurse with a history of GI upset
an RN from a maternity floor is reassigned to the ER. which of the following assignments is MOST appropriate for this nurse?
a patient at 20 weeks gestation complaining of a small amount of vaginal bleeding
the charge nurse supervises care of patients of the medical/surgical unit. the charge nurse determines care is appropriate if which of the following tasks is delegated to a nursing assistant?
a patient diagnosed with chronic obstructive pulmonary disease needs vital signs taken
an RN assess clients for the day shift. the nursing team includes on RN tow LPN/LVNs and four nursing assistants. the nurse determines that assignments are appropriate if which of the following patients is assigned to a nursing assistant?
a patient diagnosed with chronic renal failure requiring intake and output
which client assignment on a maternity unit should the nursing assistive person question?
administer acetaminophen for pain to a mother who has an episiotomy
the nursing team consists of one RN, one LPN/LVN, and two unlicensed assistive personnel (UAP). which of the following patients should the nurse on the pediatric unit assign to the LPN/LVN?
an infant required bacitricin on the circumcision site
the nursing team consist of two RNs, two LPN/LVNs and two nursing assistive personnel. which client assigned to the LPN/LVN, will the LPN/LVN question?
an infant with a palpable olive-shaped mass in the epigastrium and frequent vomiting
the nursing team consists of two RNs, two LPN/LVNs, and two nursing assistive personnel (NAP). Which client should the nurse assign to the nursing assistive personnel?
assist an elderly client with lunch
an RN has received the assignment for the night shift. which task is appropriate for the nurse to delegate to a nursing assistive person with 20 years of experience?
bathe a client prior to the scheduled 0600 surgery
an RN discusses delegation with a new nurse. which of the following statements by the new nurse indicates an understanding of the meaning of delegation?
delegation occurs when an RN assigns a specific function or aspect of patient care to an LPN/LVN or UAP
the nurse inserts and IV into a client diagnosed with acquired immunodeficiency syndrome (AIDS). the client moves, and the used needle sticks into the nurse's forearm. which action best describes OSHA's requirements for what the employer must provide in this situation?
immediate medical evaluation and treatment
a day shift nurse gives change of shift report to the next nurse. the nurse knows which information is inappropriate for the nurse to include in the change of shift report.
nurses' opinions about clients
The RN has assessed clients on the psychiatric unit. Which activity is appropriate for the nurse to delegate to a nursing assistive person on a psychiatric unit?
perform 30 min check on each client
the nursing team consists of two RNs, two LPN/LVNs, and two nursing assistive personnel. the nurse should consider the assignment appropriate if an LPN/LVN is required to complete which task?
perform a sterile dressing change
the nurse understands that risk management, within the context of managed care, focuses on which principle?
prevent and minimize institutional treatment factors that could lead to legal liability.
the nurse manger delegates a task to another staff member. which of the following includes appropriate techniques to use when delegating? Select all that apply.
the nurse manager maintains eye contact. The nurse manger states what, how, and when a task should be performed
a client is admitted with a stroke. the nurse notes the client has difficulty swallowing and requires assistance with bathing, toileting, and feeding. the delegation is appropriate if the RN delegates the tasks of bathing ad toileting to which staff member?
the nursing assistive person
the registered nurse assigns a patient diagnosed with a myocardial infarction (MI) to another registered nurse. The patient receives the wrong medication by the assigned RN. The assigning nurse knows that which of the following is true?
when an RN assigns care to another RN, both accountability and responsibility are transferred.
