Leadership Exam 1

A medsurge nurse gets floated to a labor and delivery floor. You were given a patient who has preeclampsia. Can you take care of this patient?

Yes! High blood pressure is a s/s of preeclampsia. If they go into a preeclampsic state they could go into a seizure. Medsurge nurses take care of patient's with high blood pressure and seizure patients!

You are asked to float to a different nursing unit. During report, you are told that the patient is receiving IV administration of vincristinte that should be completed within the next 15 minutes. The IV site is intact, and the patient is not having any problems with the infusion. You are not certified in chemotherapy administration. Which is your priority action? 1. Ask the nurse to stay until the infusion is finished b/c you are not certified 2. Assess the IV site; check the progress of the infusion and the patient's condition 3. Contact the charge nurse and explain that you are not chemotherapy certified 4. Look up the drug side effects because the infusion is almost completed

ANS: 1. Ask the nurse to stay until the infusion is finished b/c you are not certified RATIONALE: WRONG CIRCUMSTANCE PERSON: the nurse can float Task: look for education and scope of practice for the nurse. A nurse can assess but cannot give chemo (wrong circumstance). In this care 1st let the charge nurse know she can't administer chemo so she can't administer chemo. 2nd the previous nurse will finish the chemo IV infusion, and the floated nurse will do the other medications. It would be wrong task if the nurse had to infuse the chemo, but in this case the chemo was already infused. It is wrong circumstance because now they're asking the nurse to watch out for the patient to see if there are any side effects, but the nurse is not certified and does not know what to assess for. If the nurse was asked to do something else like hang the IV bag of NS she can do that task, but she cannot infuse chemo.

Knowledge Check: A client presents to the ED reporting severe substernal chest pain radiating down his left arm. He is admitted to the corornary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment is a priority on admission to the CCU? 1. Begin continuous cardiac monitoring 2. Obtain information about family history of heart disease 3. Auscultate lung fields 4. Determine if the client smokes

ANS: 1. Begin continuous cardiac monitoring RATIONALE: We want to see if the patient's MI is getting worse. Anytime we transfer a patient to a higher level of care we always want to use continuous cardiac monitoring.

All of the nursing activities are included in the care plan for a 78 y/o w/ Parkinson's disease who has been referred to your home agency. Which activities will you delegate the UAP. Select all that apply. 1. Checking for orthostatic changes in pulse and BP 2. Assessing for improvement in tremor after levodopa is given 3. Reminding the client to allow adequate time for meals 4. Monitoring the signs of toxic reactions to anti-Parkinson's medications 5. Assisting the client w/ prescribed strengthening exercises 6. Adapting the client's preferred activities to his level of function

ANS: 1. Checking for orthostatic changes in pulse and BP 3. Reminding the client to allow adequate time for meals 5. Assisting the client w/ prescribed strengthening exercises RATIONALE: 1. UAP's are still checking VS 5. Reminding and assisting the patient to do ROM

You are providing nursing care for a patient w/ acute kidney failure whom a nursing diagnosis of Excess Fluid Volume r/t compromised regulatory mechanisms has been identified. Which actions should you delegate to an experienced UAP? Select all that apply. 1. Measuring and recording VS every four hours 2. Weighing the patient every morning using a standard scale 3. Administering furosemide 40 mg orally 2x daily 4. Reminding the patient to save all the urine for intake and output measurements 5. Assessing breath sounds every 4 hours 6. Ensuring that the patient's urinal is within reach

ANS: 1. Measuring and recording VS every four hours 2. Weighing the patient every morning using a standard scale 4. Reminding the patient to save all the urine for intake and output measurements 6. Ensuring that the patient's urinal is within reach RATIONALE: 1. ROUTINE 2. ROUTINE 4. Not teaching and it is the CNA's job to do I&O measurements 6. Part of the plan of safety outcome for the patient

Knowledge Check: A patient enters the emergency department complaining of chest pain that is radiating down the left arm. The emergent treatment plan for this patient include(s) which nursing action(s)? SATA 1. Morphine IV 2. Aspirin 3. Oxygen 4. Heparin drip at 100 units per hour 5. Nitroglycerine tablet sublingual

ANS: 1. Morphine IV 2. Aspirin 3. Oxygen 5. Nitroglycerine tablet sublingual RATIONALE: Assuming this person is having an MI. MONA --> Morphine, Oxygen, Nitroglycerine, Aspirine this is the treatment plan for MI

Knowledge Check: A nurse is providing care to a patient with delirium. Which interventions would be most appropriate to implement? SATA 1. Providing a calm, quiet environment 2. Supervising nutritional intake 3. Using familiar cues about the environment 4. Administer psychoactive drugs 5. Keeping the patient awake as much as possible

ANS: 1. Providing a calm, quiet environment 2. Supervising nutritional intake 3. Using familiar cues about the environment

A 26 y/o G1P1 patient who underwent cesarean section 24 hours ago tells the nurse she is having some trouble breastfeeding. Which tasks could be appropriately delegated to the UAP on the postpartum floor? Select all that apply/ 1. Providing the mother w/ an ordered abdominal binder 2. Assisting the mother w/ breastfeeding 3. Taking the mother's VS 4. Checking the amount of lochia present 5. Assisting the mother w/ ambulation

ANS: 1. Providing the mother w/ an ordered abdominal binder 3. Taking the mother's VS 5. Assisting the mother w/ ambulation RATIONALE: 1. the UAP is just PROVIDING equipment!! Not applying it. 2. it is the nurse's job to assist w/ breastfeeding 3. UAP can do routine VS 5. UAP can assist w/ ambulation

You are caring for a newly admitted client w/ increasing dyspnea, hypoxia, and dehydration who has possible avian influenza ("bird flu"). Which of these prescribed actions will you implement first? 1. Start oxygen using a non-rebreather mask 2. Infuse 5% dextrose in water at 100mL/hr 3. Administer first dose of oseltamivir 4. Obtain blood and sputum specimens

ANS: 1. Start oxygen using a non-rebreather mask RATIONALE: ABC's

You delegate the measurement of VS to an experienced UAP. Osteomyelitis has been diagnosed in a patient. Which VS would you instruct the UAP to report immediately? 1. Temp of 38.3 C (101 F) 2. BP of 136/80 3. HR of 96 bpm 4. RR of 24 breaths/min

ANS: 1. Temp of 38.3 C (101 F) RATIONALE: 1. Temp of 101 is pretty high, we'd expect a low grade fever 4. 24 breaths/min we expect the patient to compensate for infection

You are working w/ a UAP to care for a client who has had a right lumpectomy and axillary lymph node dissection. Which nursing action can you delegate to the UAP? 1. Teaching the client why NP measurements are taken on the LT arm 2. Elevating the client's arm on 2 pillows to promote lymphatic drainage 3. Assessing the client's right arm for lymphedema 4. Reinforcing the dressing if it becomes saturated

ANS: 2. Elevating the client's arm on 2 pillows to promote lymphatic drainage RATIONALE: 1. its the RN's job to TEACH 2. UAP's can elevate, reposition, and turn 3. its the RN's job to ASSESS 4. its the RN's job to REINFORCE???

Knowledge Check: A nurse is observing a newly licensed nurse and an assistive personnel (AP) pull a client up in bed using a drawsheet. Which of the following actions by the newly licensed nurse indicates an understanding of this technique? 1. The nurse stands w/ his feet together 2. The nurse uses his body weight to counter the client's weight 3. The nurse's feet are facing inward, toward the center of the bed 4. The nurse uses the muscles in his back to life the client off the bed using the drawsheet

ANS: 2. The nurse uses his body weight to counter the client's weight

A patient has a fractured femur. Which finding would you instruct the UAP to report immediately? 1. The patient reports pain 2. The patient appears confused 3. The patient's blood pressure is 136/88 mg Hg 4. The patient voided using the bedpan

ANS: 2. The patient appears confused RATIONALE: 1. pain is expected with a fractured femur!! UAP would report it, but it is the the immediate priority 2. fat embolism syndrome 3. pain caused the BP to increase 4. expected

Knowledge Check: What is a common cause of a manager to under delegate? 1. A high degree of trust in subordinates 2. A Democratic leader ship style 3. A need for perfectionism 4. Sufficient time to accomplish unit goals alone

ANS: 3. A need for perfectionism This type of manager wants everything to be perfect and so they will do it themselves which will take more time

Knowledge Check: A patient in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop though." Based on this statement, which priority assessment should the nurse complete? 1. Check for presence of tortuous veins bilaterally on the legs 2. Ask about any changes in skin color that occur in response to cold 3. Attempt to palpate the dorsalis pedis and posterior tibial pulses 4. Assess for unilateral swelling and tenderness of other leg

ANS: 3. Attempt to palpate the dorsalis pedis and posterior tibial pulses RATIONALE: To make sure there is no occlusion!

Knowledge Check: A patient is brought into the emergency department w/ chemical burns to both eyes. What is the priority action of the nurse for this patient's care? 1. Administering local anesthetics and anti-bacterial drops fro 24-36 hours 2. Applying hot compresses at 15 minute intervals 3. Flushing the lids, conjunctiva and cornea w/ tap water or normal saline 4. Cleansing the conjunctiva w/ a small cotton-tipped applicator

ANS: 3. Flushing the lids, conjunctiva and cornea w/ tap water or normal saline Must get it out immediately!

Knowledge Check: Which statement is true regarding the general delegation liability of the registered nurse (RN)? 1. It is minimal because subordinates alone are held accountable for practicing within the accepted scope of practice for their job description 2. It is great because the RN is automatically held liable for the tasks delegated to all recognized subordinates 3. It is reduced when the RN appropriately assesses what and to whom delegation is appropriate and supervises the completion of the tasks 4. It is avoided entirely by delegating tasks to only other licensed personnel

ANS: 3. It is reduced when the RN appropriately assesses what and to whom delegation is appropriate and supervises the completion of the tasks When we do not assess appropriately and we do not use the 5 rights of delegation we become more liable

Knowledge Check: What statement concerning the delegating of task by the nurse to unlicensed assistive personnel (NAP) is true? 1. One can safely assume that the NAP has at least a high school diploma as a minimum hiring criterion 2. All unlicensed assistive personnel have achieved at least minimum standardized training pursuant to the Omnibus Budget Reconciliation Act of 1987 3. No federal or community standards have been established for training the broad classification of NAP 4. The nurse is protected from liability when allowing the NAP to perform only those tasks the employee includes in the job description

ANS: 3. No federal or community standards have been established for training the broad classification of NAP

In the care of the client w/ gastroesophageal reflux disease, which task would be appropriate to assign to a UAP? 1. Sharing successful strategies for weight reduction 2. Encouraging the client to express concerns about lifestyle modification 3. Reminding the client not to lie down for 2 to 3 hours after eating 4. Explain the rationale for eating small frequent meals

ANS: 3. Reminding the client not to lie down for 2 to 3 hours after eating RATIONALE: 2. UAP could give a personal opinion

Knowledge Check: Which restraining force occurs when a subordinate test the water to determine what the consequences are of not completing a delegated task? 1. Failure of delegator to see subordinate perspective 2. Subordinate in capable of completing the task 3. Subordinate inherent resistance to authority 4. Overdelegation of specificity of the task

ANS: 3. Subordinate inherent resistance to authority We need to evaluate, reprioritize, figure out what's going on, figure out our barriers, and use our chain of command

Knowledge Check: What is an inappropriate reason for delegation? 1. To empower subordinates by stretching them in their work assignment 2. To free the manager to address more complex, higher level unit needs 3. When the task is not a challenge for the manager 4. Because someone else is better qualified to do the task that needs to be done

ANS: 3. When the task is not a challenge for the manager We always want to empower our subordinates!

You are initiating a nursing care plan for a patient w/ osteoporosis. All of these nursing interventions apply to the nursing diagnosis Risk for Fall. Which intervention should you delegate to the UAP? 1. Identifying environmental factors that increase risk for falls 2. Monitoring gait, balance, and fatigue level with ambulation 3. Collaborating with the physical therapist (PT) to provide the patient with 4. Assisting the patient with ambulation to the bathroom and in the halls

ANS: 4. Assisting the patient with ambulation to the bathroom and in the halls RATIONALE: 1. Identifying = Assessing

Knowledge Check: A member of the team reports that they have been given too much to do and are not going to be able to complete the work on time. What action will the RN take to effectively manage this situation? 1. Assign the work to another team member 2. Take on the responsibility of the task 3. Have the team member perform only the necessary tasks 4. Examine the workload and assist the individual in reprioritizing

ANS: 4. Examine the workload and assist the individual in reprioritizing

Knowledge Check: Which organization is actively engaged in clarifying the delegation parameters for RN? 1. American Hospital Association (AMA) 2. The federal government 3. National League for Nursing (NLN) 4. State Boards of Nursing Licensure

ANS: 4. State Boards of Nursing Licensure

Knowledge Check: The health care provider is caring for a patient diagnosis w/ a mild cognitive impairment. Which of these would be the most effective intervention for this patient? 1. Frequent reorientation 2. Relaxation therapy 3. Behavior modification 4. Application of soft restraints

ANS: 1. Frequent reorientation Reorientate a patient as much as possible! Reorient them to person, place, and time

Knowledge Check: Nurse is caring for a client who has diabetes mellitus and had a morning blood glucose level of 285 mg/dL. An assistive personnel (AP) reports that a client's finger-stick blood glucose reading 30 min before lunch is 58 mg/dL. Which of the following actions should the nurse take? 1. Recheck the client's blood glucose 2. Complete a facility incident report 3. Inform the AP to give the client 120 m: of orange juice 4. Administer insulin as prescribed

ANS: 1. Recheck the client's blood glucose Until you check it again you would go onto a remedy.

Knowledge Check: What are the 3 elements of delegation? 1. Responsibility 2. Authority 3. Legality 4. Accountability

ANS: 1. Responsibility 2. Authority 4. Accountability The primary goal for the nurse as far as delegation is responsible and accountable for delegating.

Knowledge Check: The easiest way to make sure you're delegating properly is to follow the 5 R's 1. Right Task 2. Right Circumstance 3. Right Position 4. Right Direction/Communication 5. Right Person

ANS: 1. Right Task 2. Right Circumstance 4. Right Direction/Communication 5. Right Person The last right is Right Supervision

Knowledge Check: A nurse on an acute care unit is caring for a client following a total hip arthroplasty's. The client is confused and is moving his leg into positions that could dislocate the new hip joint, and he repeatedly attempts to get out of bed. After determining that restraint applications is indicated, which of the following actions should the nurse take? SATA 1. Secure the restrain to the frame of the bed. 2. Get a prescribed for restraints from the provider. 3. Have the family member sign the consent for restraints. 4. Use a square knot to secure the restraints on the bed 5. Ensure that only one finger can be inserted between the restraint and the client.

ANS: 1. Secure the restrain to the frame of the bed. 2. Get a prescribed for restraints from the provider. 3. Have the family member sign the consent for restraints. If the patient is confused and is on a surgical floor! You must let the family member to sign a consent for restraints so they don't dislocate their hip.

Knoweldege check: A nurse is reviewing the hospital's fire safety policies and procedures with newly hired assistive personnel. The nurse is describing what to do when there is a fire in a client's trash can. Which of the following information should the nurse include? SATA 1. The first step is to pull the alarm 2. Use a Class C fire extinguisher to put out the fire 3. Instruct ambulatory clients to evacuate to a safe place 4. Pull the pin on the fire extinguisher prior to use 5. Close all doors

ANS: 3. Instruct ambulatory clients to evacuate to a safe place 4. Pull the pin on the fire extinguisher prior to use 5. Close all doors RATIONALE: The fire is in the patient's trash can in their room. So, the patient and family should evacuate to a safe place.

Based on the information you have obtained, you develop a care plan. Which nursing activities will you delegate to a home health aide? Select all that apply. 1. Setting up the client's medications in a multidose pill box twice a week 2. Instruct the daughter on how to set up the client's daily medications 3. Teaching the client and her daughter the purpose of each medication 4. Assisting the client w/ a bed and personal hygiene every day 5. Measuring VS daily 6. Weighting the patient daily 7. Auscultating lung and heart sounds weekly 8. Checking for any peripheral edema weekly

ANS: 4. Assisting the client w/ a bed and personal hygiene every day 5. Measuring VS daily 6. Weighting the patient daily Not 1 b/c it is not in their scope of practice to know what medications to schedule for whichever days Not 2 b/c it is INSTRUCTING/ TEACHING Not 3 b/c it is INSTRUCTING/ TEACHING Not 7 b/c auscultating is not w/in their scope of practice and it is as ASSESSMENT Not 8 b/c it is ASSESSMENT

A client with atrial fibrillation is ambulating in the hallway on the coronary stepdown unit and suddenly tells you, "I feel dizzy." Which action should you take first? 1. Help the client to sit down 2. Check the client's apical pulse 3. Take the clients BP 4. Have the client breath deeply

ANS: 1. Help the client to sit down RATIONALE: First action is safety, then we will take their VS

Which goal is a priority after surgical repair of a cleft lip? 1. Manage pain 2. Prevent infection 3. Increase mobility 4. Develop parenting skills

ANS: 2. Prevent infection RATIONALE: KEY WORD is surgery Systemic >> Local infection >> pain

A ten-year old child is admitted w/ a brain tumor. Which assessment made by the nurse is most critical to report to the child's healthcare provider (HCP)? 1. vomiting after lunch 2. difficulty recalling the day of the week 3. a moderate amount of serous fluid was noted on the lumbar dressing 4. 100mL of concentration urine voided at one voiding

ANS: 2. difficulty recalling the day of the week RATIONALE: 2. it is critical to you because there is a change in mental status! NEURO --> Glasgow coma check Neuro trumps everything; if the tumor is getting bigger and now the patient cannot recall the day of the week then there's something going on in their head. LOC

An abused child is admitted to the hospital and the nurse is aware that a court appearance may be necessary. To plan for this eventuality, what should be the priority? 1. remember the parents' and child's behavior when the child was admitted 2. document physical findings and behaviors during the child's admission 3. formulate subjectives opinions about the cause of any injury 4. prepare answers to questions that may be asked by the attorney

ANS: 2. document physical findings and behaviors during the child's admission

The nurse walks into the room and finds that the client who has just had surgery is diaphoretic, appears to have no respirations, and has a barely palpable pulse. The nurse should first: 1. call a code 2. open the airway 3. start rescue breathing 4. start cardiac compressions

ANS: 2. open the airway RATIONALE: ABCDE's Framework First is Airway! KEYWORD: "barely palpable pulse" --> no need to call a code yet

The nurse is working on a birthing unit w/ an unlicensed assistive personnel (UAP). The nurse determines that the UAP understands the type of information to report to the nurse when the UAP reports which information about one of the clients? 1. An episode of nausea after administration of an epidural anesthetic 2. Contractions 3 min apart and lasting 40 seconds 3. Evidence of spontaneous rupture of the membranes 4. Sleeping after administration of IV nalburphine

ANS: 3. Evidence of spontaneous rupture of the membranes Not 1 because it is ASSESSING, they can have nausea after eating Not 2 because it is ASSESSING and EVALUATING

A client has just undergone a lumbar puncture (LP). Which findings should the nurse immediately report to the healthcare provider (HCP)? 1. the client's oral intake was 1,200 mL in the past 8 hours 2. the client required analgesia for headache 3. moderate amount of serous fluid was noted on the lumbar dressing 4. the client is concerned about the test results

ANS: 3. moderate amount of serous fluid was noted on the lumbar dressing RATIONALE: PRIORITY FRAME WORK this is an assessment and assessment goes first

Which topic would be most important to include when teaching the parents how to promote overall toddler development? 1. language is the most important achievement 2. discipline is critical to appropriate development 3. safety is a priority concern for this age group 4. eating habits that follow into adulthood begin now

ANS: 3. safety is a priority concern for this age group RATIONALE: Safety >> everything

A female client who is hospitalized for an eating disorder weighs 15 lbs. less than the ideal body weight. Which goal is a priority for this client? 1. the client attends all eating disorders support groups 2. the client eats bigger meals at breakfast 3. the client gains 1 lb/week 4. the client reports an improved self-image

ANS: 3. the client gains 1 lb/week RATIONALE: Use Maslow's Hierarchy of Needs Priority setting framework!! 1. is is an intervention 2. is an intervention 3. PRIORITY! look at frameworks! Physiological needs come first. Gaining 1 lbs a week is a physiological need b/c she is underweight!! She is not getting her nutrition causing nutrition and electrolyte imbalance which can put the patient's at risk for other things. 4. with all the other options it will improved self-image which is an end goal

The nurse observes that a client who has received midazolam for conscious sedation is having shallow respirations. The nurse should do all except: 1. encourage the client to deep breathe 2. have respiration equipment in the room 3. administer oxygen as prescribed 4. administer naloxone

ANS: administer naloxone RATIONALE: Naloxone is used to reverse opioids. Midazolam is a benzodiazepine. Reversal for midazolam is flumazenil

You're a medsurge nurse and is floated to another floor. The charge nurse assigns you to a patient that had chemo one day ago OR just received chemo an hour ago. Can you take care of the patient?

Yes! The medication has already been administered. All you need to do is monitor the patients for side effects like N&V, diarrhea. You already do that on a med surge.

The client w/ a nasogastric (NG) tube has abdominal distention. Which should the nurse do first? 1. call the healthcare provider 2. irrigate the NG tube 3. check the function of the suction equipment 4. reposition the NG tube

ANS: 3. check the function of the suction equipment CHECK EQUIPMENT ALWAYS example: if you're walking down the hall and you hear an IV pump beeping you're going to check to see what's wrong!

A client's abdominal incision eviscerates. The nurse should first: 1. take the client's VS and call the healthcare provider (HCP) 2. lower the client's head and elevate the feet 3. cover the incision w/ a dressing moistened w/ sterile normal saline solution 4. start an emergency infusion of IV fluids

ANS: 3. cover the incision w/ a dressing moistened w/ sterile normal saline solution Rationale: the nurse has already assess the situation because to know that the abdominal incision eviscerated, you have to look to see the organs are coming out. So the next part of the nursing process is plan/intervention. We will want to notify the HCP after we have completed all the interventions.

You're a medsurge nurse and is floated to another floor. The charge nurse assigns you to a patient that needs chemotherapy. You have never given chemotherapy. Do you have the skills and knowledge?

No! You are the WRONG PERSON. You are a RN, but you are the wrong person. You don't have the SKILLS/KNOWLEDGE!!

You are a new grad nurse is just got hired for ICU. You're a nurse just like everyone else. There is a patient who is fresh out of open heart surgery. Can you be assigned to that patient?

No! You have not received the training for it. However, if you're going to be trained for it, you're going to work with a nurse 2-3 times before being able to do it on your own! You don't have to be certified to care for those patients, but you need the proper training.

Knowledge Check: Which assessment must be RN do initially when assigning tasks to non-licensed personnel (NAP)? 1. Evaluating the NAP's skills and knowledge level 2. Assessing which tasks the NAP is interested in assuming 3. Evaluating how patients rate the NAP's performance 4. Assessing how team members like working with the NAP

ANS: 1. Evaluating the NAP's skills and knowledge level We must supervise and evaluate!

You're a medsurge nurse and is floated to another floor. The charge nurse assigns you to a patient that had just been diagnosed with cancer can you take care of the patient?

No!