NCLEX-PN 7th ed. Test review: Ch 7 prioritizing patient care: leadership, delegation and emergency response planning

(LPN) or (LVN)

can perform not only the tasks that a nursing assistant can perform but also certain invasive tasks, such as dressing changes, suctioning, urinary catheterization, and medication administration (oral, subcutaneous, intramuscular, and selected piggyback medications), according to the education and job description of the can also review teaching plans with the client that were initiated by the registered nurse (RN)

A nursing care plan

written guideline and communication tool that identifies the client's pertinent assessment data, client problems, goals, interventions, and expected outcomes and provides a framework for evaluation of the client's response to nursing actions.

1. As-needed

21. The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included? 1. As-needed medications given that shift 2. Normal vital signs that have been normal since admission 3. All of the tests and treatments the client has had since admission 4. Total number of scheduled medications that the client received on that shift

A client who requires frequent ambulation

22. The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)? 1. A client who requires wound irrigation 2. A client who requires frequent ambulation 3. A client who is receiving continuous tube feedings 4. A client who requires frequent vital signs after a cardiac catheterization

A client who requires a 24-hour urine collection

23. The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)? 1. A client who requires a 24-hour urine collection 2. A client who requires twice-daily dressing changes 3. A client with diabetes mellitus who requires daily insulin and the reinforcement of dietary measures 4. A client who has been placed on a bowel management program and requires rectal suppositories and a daily enema

Nursing staff are led by the nurse when providing care to a group of clients

27. The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team-based model of nursing practice? 1. A task approach method is used to provide care to clients. 2. Managed care concepts and tools are used when providing client care. 3. Nursing staff are led by the nurse when providing care to a group of clients. 4. A single registered nurse is responsible for providing nursing care to a group of clients.

Level I Disaster

A massive disaster that involves significant damage and results in a presidential disaster declaration, with major federal involvement and full engagement of federal, regional, and national resources.

Level III Disaster

A minor disaster that involves a minimal level of damage but could result in a presidential declaration of an emergency.

Level II Disaster

A moderate disaster that likely will result in a presidential declaration of an emergency, with moderate federal assistance.

an unlicensed assistive personnel (UAP).

In general, noninvasive interventions, such as skin care, range-of-motion exercises, ambulation, grooming, and hygiene measures, can be assigned to

(Yellow) require treatment within 1 to 2 hours and evaluation every q30-60min

Priority 2

(Green) can wait several hours for medical treatment. eval q2h

Priority 3

(Red) life-threatening need continuous evaluation

Priority one

right task, right circumstances, right person, right direction/communication, and right supervision/evaluation

The 5 rights of delegation are

Functional nursing:

This type of system is task-oriented, and the team member focuses on the delegated task rather than the total client. This results in fragmentation of care and lack of accountability by the team member.

A client who is dependent on a ventilator

24. The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first? 1. A client in skeletal traction 2. A client who is dependent on a ventilator 3. A postoperative client preparing for discharge 4. A client admitted during the previous shift with a diagnosis of gastroenteritis

A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

25. The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client? 1. A client complaining of muscle ache, headache, and malaise 2. A client who twisted their ankle when they fell in-line skating 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

. 2, 3, 5

26. The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply. 1. "An event is termed a mass casualty when it overwhelms local medical capabilities." 2. "Mass casualty events do not require an increase in the number of staff that are needed." 3. "A mass casualty event occurs only within the heath care facility and could endanger staff." 4. "Mass casualty events may require the collaboration of many local agencies to handle the situation." 5. "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

Autocratic

28. A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style? 1. Autocratic 2. Situational 3. Democratic 4. Laissez-faire

Perform follow-up with each staff member regarding the performance and outcome of the task.

29. The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of tasks? 1. Document that the task was completed. 2. Assign the tasks that were not completed to the next nursing shift. 3. Allow each staff member to make judgments when performing the tasks. 4. Perform follow-up with each staff member regarding the performance and outcome of the task.

A client receiving oxygen who is having difficulty breathing

30. The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first? 1. A client scheduled for a chest x-ray 2. A client requiring daily dressing changes 241 3. A postoperative client preparing for discharge 4. A client receiving oxygen who is having difficulty breathing