Funds- Prioritizing Client Care

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

1 Rationale: The airway is always a priority, and the nurse first checks the client on a ventilator.

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the 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

2 Rationale: The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the UAP would be to care for the client who requires frequent ambulation. The UAP is skilled in this task. The client who had a cardiac catheterization will require specific monitoring in addition to that of the vital signs. Wound irrigations and tube feedings are not performed by UAP

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 3. A postop client preparing for discharge 4. A client receiving oxygen who is having difficulty breathing

4 Rationale: the airway is always a priority, and the nurse would attend to the client who has been experiencing an airway problem first

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 tests and treatments the client has had since admission 4. Total number of scheduled medications that the client received on that shift

1 Rationale: The nursing hands off report needs to be an efficient and accurate account of the clients condition during the last shift. It needs to include pertinent information about the client such as tests and treatments; as needed medications given or therapies performed during the past 24 hours,

The nurse is educating a new nurse about mass casualty event (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 health care facility and could endanger staff 4. A mass casualty event occurs if a fight between visitors occur in the ED 5. Mass casualty events may require the collaboration of many local agencies to handle the situation

2, 3, 4 Rationale: Mass casualty events, also known as disasters, overwhelm local medical capabilities and may require the collaboration of multiple agencies and health care facilities to handle the crisis. This type of event can occur in the health care facility or outside of it. Fights in the ED are not termed mass casualty events but are agency security and require an increase in staffing to ensure safe patient care

The nurse has delegated several nursing tasks to staff members. Which is the nurses primary responsibility after the delegation of the 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 tasks 4. Perform follow up with each staff member regarding the performance and outcome of the task

4 Rationale: the ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurses primary responsibility to follow up with each staff member regarding the performance of the task and the outcomes related to the implementing the task. Not all staff members have the education, knowledge, and ability to make judgements about tasks being performed. The nurse documents that the task has been completed, but this would not be done until follow up was implemented and outcomes were identified.

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 UAP? 1. A client who requires a 24 hour urine collection 2. A client who requires twice daily dressing changes 3. A client who is on a bowel management program and requires rectal suppositories and a daily enema 4. A client with diabetes mellitus who requires daily insulin and the reinforcement of dietary measurements

1 Rationale: The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. The assignment of tasks needs to be implemented on the basis of the job description of the individual, the individual's level of clinical competence, and the state law

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 understands that which is a characteristic of this type of nursing model of 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 RN is responsible for providing nursing care to a group of clients

3 Rationale: in team nursing, nursing personnel are led by the nurse when providing care to a group of clients.

The nurse employed in the ED is assigned to assist with the triage of clients arriving to the ED. The nurse should assign priority to which client? 1. A client complaining of muscle aches, a headache, and malaise 2. A client who twisted her ankle when she 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 he just ate pizza that was mad with a very spicy sauce

4 Rationale: In an ED, triage involves classifying clients according to their need for care, and it includes establishing priorities of care. The type of illness, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, or acute neurological deficits, and those who sustained a chemical splash to the eyes are classified as emergent, and these clients are the number 1 priority.

A client experiences a 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

1 Rationale: autocratic leadership is an approach in which the leader retains all authority and is primarily concerned with task accomplishments. It is an effective leadership style to implement in an emergency or crisis situation/ The leader assigns clearly defined tasks and established one way communication with the work group, and he or she makes all decisions independently. Situational leadership is a comprehensive approach that incorporates the leaders style, the maturity of the work group, and the situation at hand. Democratic leadership is a people centered approach that is primarily concerned with human relations and teamwork. This leadership style facilitates goal accomplishment and contributes to the growth and development. Laissez-faire leadership is a permissive style in which the leader gives up control and delegates all decision making in the work group