LSHIP-Total, lp

The RN is assessing the client's daily schedule and habits. Which question is most appropriate for the RN to ask the client?

"What time do you prefer bathing and do you take a tub bath or shower?"

4.Community outbreak of meningitis, discharges needed, the most appropriate to discharge is...

-50yo M W/rotation cuff surgery, STABLE

1.Hypersensitive med → wrong client. What are your next actions in order:

-V/S -Instruct pt. to stay in bed -Call HCP -Complete incident report -Notify risk management officer

4. A nurse manager is reviewing safe delegation practices w/nurses. Which is an appropriate statement by the nurse manager?

"All delegated tasks require follow-up to ensure compliance." Rationale: Monitoring of performance to ensure compliance is a principle of safe delegation practice

In a job interview for a staff position, which of the following indicates your knowledge of patient safety?

"Is there a strategy in place to reduce the number of overtime hours on the unit?"

A nursing filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?

"The client was lying on the floor next to his bed."

A nurse is teaching a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching?

"This means I have outlined my wishes for medication treatment."

5 rights of delegation

1. right task 2. right circumstance 3. right person (delegatee) 4. right direction and communication 5. right supervision and evaluation

The charge nurse is planning the assignment for the day. What factors should the nurse remain mindful of when planning the assignments? (Select all that apply) 1. the acuity level of the clients 2. specific requests from the staff 3. the clustering of the rooms on the unit 4. the number of anticipated client discharges 5. client needs and workers' needs and abilities

1. the acuity level of the clients 5. client needs and workers' needs and abilities NCLEX

6.Actions to take when fire starts: (MASE)

1.Move clients 2.Activate alarm 3.Shut fire doors 4.Estinguish

Which of the following skills can be delegated to nursing assistive personnel (NAP)? (Select all that apply.) 1. Nasotracheal suctioning 2. Oropharyngeal suctioning of a stable patient 3. Suctioning a new artificial airway 4. Permanent tracheostomy tube suctioning 5. Care of an endotracheal tube (ETT)

2. Oropharyngeal suctioning of a stable patient 4. Permanent tracheostomy tube suctioning Fundamentals text ch 41

A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following client's needs should the nurse assign to an assistive personnel (AP)? 1. Feeding a client who was admitted 24 hr ago with aspiration pneumonia 2. Reinforcing teaching with a client who is learning to walk using a quad cane 3. Reapplying a condom catheter for a client who has urinary incontinence 4. Applying a sterile dressing to a pressure ulcer

3. Reapplying a condom catheter for a client who has urinary incontinence -client with pneumonia is at risk for aspiration so it is inappropriate to delegate the feeding to an AP -reinforcing teaching and sterile dresses are within the scope of practice of PNs and RNs ATI Fundamentals ch 6

A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?

A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL

53. A nurse is assigned four postop clients. Which clients should the nurse address first?

A client whose BP at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg Rationale: 0800 BP = prehypertensive (systolic 129-139, diastolic 80-89), usual for postop, (stress of surgery, pain, and IV fluid); 1200 BP = norm (systolic 90-120, diastolic 60-80); Concern=BP drop may indicate internal bleeding, LVN report → RN

Who is a key stakeholder that is a critical part of the informatics team when attempting to implement an electronic documentation system?

A super user who is a shift expert

The unit is shifting from primary nursing to a team model in an effort to contain costs. Staff members are angry and ask for a meeting to discuss the change. After hearing their concerns related to reduction in professional autonomy and care quality, yo

Acknowledge the loss

A nurse is caring for a client who has stage 4 ovarian cancer and has decided to stop treatment and enter hospice care

Advocacy

Team members are becoming disillusioned with the group performance. The team leader is seeking a method to get members engaged.Which option would help to promote engagement among team members?

Agenda should be sent out to team members prior to the meeting of the team

39. A nurse on a peds unit is reviewing her client assignment following the shift report. Which client should be seen first?

An infant with pertussis receiving oxygen via nasal cannula Rationale: Using the airway, breathing, circulation (ABC) approach to prioritizing client care

An RN and a licensed practical nurse are caring for a client who has a small bowel obstruction and is NPO with a NG tube set to continuous suction

Assess for bowel sounds every 2 hr

The nurse is caring for a patient that has limited vision. Which ethical principle is the nurse upholding by ensuring that there are no obstacles present between the patient's bed and the bathroom?

Beneficence

2. What is continuity of care?

Completion of proper discharge from one facility to another

. A nursing instructor is teaching a class on conflict resolution. She relates to the class that conflict in an organization is important, and that an optimal level of conflict will do the following: Generate:

Creativity, a problem-solving atmosphere, a strong team spirit, and motivation for its workers

Transferring the authority and responsibility to another health care team member to complete a task while retaining the accountability is called

Delegation

. A nurse requests a schedule change due to a family issue. The nurse manager states, "If you cannot come in, we will figure it out." The NM is demonstrating what type of leadership style?

Democratic

A nurse manager calls a meeting of the unit's staff members to discuss cost-contaminment issues

Democratic

12. Wrist restraints to a client who is confused and attempting to pull out a chest tube. Which would be an appropriate action?

Document client action that necessitated the restraints

A nurse is participating in a biological disaster simulation where citizens are exposed to pneumonic plague. Which of the following isolation precautions should the nurse plan to use while caring for these clients?

Droplet

Which rules should be incorporated by nurse managers and leaders in order to maintain synergy when working with team development? (select all that apply)

Each member of the team should be able to state the intended purpose of the team , Team members should share objective feedback,Team members are encouraged by leadership to share ideas

Which task should the RN delegate to the UAP

Empty the Jackson Pratt Drain and record the amount

A nurse is caring for a client who requests pain medication. The nurse fulfills a promise to return with the medication within 15 min. The nurse is demonstrating which of the following ethical principles?

Fidelity

52. A severe storm resulted in an RN working with one AP on the unit. Which action by the nurse is appropriate?

Focus on providing care that prevents life-threatening emergencies Rationale: The hospital implements the triage method in a disaster, focuses on providing care to any immediate threats to life

A nurse is working with an interdisciplinary disaster committee to develop a community-wide emergency response plan in the event of a non-biological or chemical incident. The nurse should include which of the following agencies to be notified immediately after calling 911?

Office of Emergency Management (OEM)

A home health nurse is assessing the safety of a client's home. Which of the following factors may increase the client's risk for falls? (Select all that apply).

Reduced vision- Impaired memory- House slippers- Kyphosis- HX of Falls

56. A nurse is working w/AP and reviewing the list of tasks that have been delegated. Which tasks requires clarification?

Removing and cleaning the cannula of a client with a new tracheostomy Rationale: requires assessment, knowledge, judgment and skill, and is a task that cannot be delegated by the nurse

49. A nurse is caring for a client. How should the nurse verify client's durable power of attorney?

Review paperwork completed upon admission Rationale: The legal document should be placed in client's current medical record upon admission

A nurse asks a newly hired assistive personnel (AP) to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take to ensure the AP is qualified to perform this task?

Review the AP's skill competency checklist.

A nurse is reviewing laboratory results for a client who is at 12 weeks gestation.

Serum creatinine 0.4mg/dL

35. A licensed PN is providing care to a client who has COPD. Which findings should be reported to the RN immediately?

Speaks in short phrases Rationale: inability to talk normally or complete a sentence without becoming SOB indicates difficulty maintaining O2 (Other signs: cyanosis, mental confusion, changes in mental status)

6. A nurse is caring for a client who is experiencing dysphagia. Which referral is appropriate at this time?

Speech therapist Rational: They assesses/makes recommendations for speech, language, & swallowing difficulties, referred for swallowing eval

Directing, monitoring, and evaluating the performance of tasks by another member of the health care team is called

Supervising

You are part of a multidisciplinary team that is charged with designing a workplace safety plan for your healthcare organization. This team has been established in response to increases in reports of violence and aggression. You begin by:

Surveying staff about levels of satisfaction with the workplace and management, collegial, and patient relations

A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?

Take an arterial blood gas (ABG) specimen to the laboratory.

A nurse is caring for several clients who require diagnostic testing and is delegating tasks to an assistive personnel. Which of the following tasks should the nurse direct the AP to perform first?

Take an arterial blood gas specimen to the laboratory

The RN is caring for a client 1 day post op sigmoid resection. There is a large amount of bright red blood on the dressing. Which intervention should the RN implement first?

Take no action because this is an appropriate delegation

A charge nurse is observing a group of newly licensed nurses. Which of the following observations should the charge nurse report to the nurse manager as a violation of HIPAA?

Talking about clients with other nurses in the cafeteria

An example of a care activity that would likely not be delegated by an RN to a UNP is (select all that apply)

Teaching self-catheterization to a patient with paraplegia who has limited English, Basic care for a patient with a head injury who is rapidly deteriorating ,Assessment of patients being admitted through the emergency department

A nurse manager is known to use an autocratic style of management. The nurses who work for this nurse manager know that this style of management leads to what possible result?

Team members may become demoralized because of the management style.

A key advantage that a nurse has in terms of delegating is that:

Team skills can be used more effectively

A key advantage that a nurse manager has in terms of delegating is that:

Team skills can be used more effectively

50. A nurse should intervene when observing an AP do which with a client's medical record?

Tears a document with client information in half before disposing of it in a waste basket Rationale: Info security protocols include shredding any printed or written client info

When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation

The AP has the knowledge and skill to perform the task

Which situation would constitute an example of "bullying", in the nursing environment?

The UAP on the unit continues to make jokes about another staff member in the presence of others as well as when alone in the staff member's presence

The RN and LPN are caring or a group of clients. Which information provided by the LPN warrants immediate attention by the RN

The client with biological response modifier who has a T: 99.2 P 68 RR 24 BP 176/96

Ms. Bonner is caring for clients on the burn unit. After the shift report which client should Ms. Bonner assess first?

The client with full thickness burns on the chest who is having trouble breathing

The clinic nurse is reviewing lab results for clients seen in the clinic. Which client requires additional assessment by the RN?

The client with hemoglobin of 9 g/dL and hematocrit of 29%

A nurse is caring for a client who is dying and unable to make decisions for himself. The client's adult children disagree on his code status

The client's health care proxy

A nurse finds that a client did not receive a scheduled dose of Furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply)

The client's vital signs- The time the client was to receive the medication- The date of the incident

A nurse on a medical surgical unit is caring for a group of clients. For which of the following situations should the nurse complete a variance report

The discovery that a preoperative client has received and eaten breakfast

5. The nurse manager is aware that which incident would be classified as a sentinel event?

The patient receives a second-degree burn from a malfunction in a hypothermia blanket

22. A new LVN is planning to perform a procedure she has not done. What resources should the nurse use?

The policy and procedure manual for the unit Rationale: other sources may offer knowledge and assistance, but they may not describe the procedure within policy

A nurse manager is participating in a root cause analysis following a sentinel event on her unit

The root cause analysis investigates deviations from standards of care surrounding the event

A group of nursing students are discussing how staffing affects patient safety. Which nursing student comment if observed by the nursing instructor would warrant intervention?

There is little evidence to support that adequate staffing leads to improved patient outcomes.

Which action supported by current research contributes to the existence of workplace violence in the clinical setting?

There is no support from administration

A unit manager of a 25-bed medical/surgical area receives a phone call from a nurse who has called in sick five times in the past month. He tells the manager that he very much wants to come to work when scheduled but must often care for his wife, who is undergoing treatment for breast cancer. According to Maslow's need hierarchy theory, what would be the best approach to satisfying the needs of this nurse, other staff, and patients?

Work with the nurse, staffing office, and other nurses to arrange his scheduled days off around his wife's treatments.

A nurse is providing discharge teaching about home safety with an older adult client and his family

You should install a handrail on at least one side of the stairs

A charge nurse receives a call from his nursing supervisor about an explosion at a local factory and an urgent need for facility beds

a 44 year old client who has asthma and admitted for carpal tunnel surgery

A nurse in an ER is caring for four clients. Which of the following findings requires the nurse to act as a mandatory reporter?

a child left unsupervised for several hrs at home and is being treated for a fractured leg

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

a. "Information about a client can be disclosed to family members at any time."

A nurse is preparing to provide discharge teaching to an older adult client. Which of the following teaching considerations should the nurse include? a. allow frequent rest periods during teaching b. use colored paper with a glossy finish

a. allow frequent rest periods during teaching

What parts of the nursing process cannot be delegated to an NAP? (Select all that apply) a. assessment b. nursing diagnosis c. planning d. intervention e. evaluation

a. assessment b. nursing diagnosis c. planning e. evaluation Leadership and Management

A nurse discovers that the wrong med was given to a confused client who answered to the name the nurse stated when entering the room. The provider is notified and states that the med the client received will cause any harm. Which of the following actions should the nurse take? a. Complete an incident report documenting the occurrence b. Make a note in the client's medical record that an incident report was completed

a. complete an incident report documenting the occurrence

A nurse manager is planning staff development activities for the unit's new AP's. Which of the following activities should the nurse manager perform first? a. determine the learning needs of the AP's b. Administer a skills pretest to the new APs

a. determine the learning needs of the AP's

A charge nurse in an ER is making assignment for an AP for a shift with unexpected staff absences. Which of the following assignments should the charge assign to a float AP from the med surg unit? a. escort clients from the ER to other areas of the facility for tests b. sit at the reception desk answering and directing clients

a. escort clients from the ER to other areas of the facility for tests

Which task should Beyonce NOT delegate to the CNA?

b. Explain the side effects of gentamycin to the patient in 6A

A home health nurse is caring for a client who asks what is included in a living will. Which of the following statements should the nurse include in the teaching? a. It establishes who will make health care decisions if the client is not able b. It allows the client to express personal wishes regarding health care decisions c. It serves as an informed consent for procedures

b. It allows the client to express personal wishes regarding health care decisions

A charge nurse is evaluating conflict resolution between two staff nurses. Which of the following conflict resolution styles is an example of one nurse putting aside her own goals to satisfy the other nurse? a. avoidance b. accommodation

b. accommodation

A nurse is caring for a pt who has stage 4 ovarian cancer and has decided to stop tx and enter hospice care. Which of the following ethical principles is the nurse displaying by supporting the client in her decision? a. Responsibility b. Accountability c. Advocacy d. Confidentiality

c. Advocacy

A group of providers are participating in a cardiopulmonary resuscitation effort for a client who is in cardiac arrest. Which of the following types of leadership for this group to function efficiently? a. transformational b. participative c. Autocratic

c. Autocratic

The charge nurse working with an RN, LPN, and a NAP is very busy with the group of pts on the unit. One pt's intravenous line has just infiltrated, a practitioner is on the phone waiting for a nurse's response, a pt wants to be discharged, and the NAP has just reported an elevated temperature on a new surgical pt. Who should be assigned to restart the intravenous line? a. LPN b. NAP c. RN d. charge nurse

c. RN Leadership and Management

A nurse is caring for a client who is a local public official. A local newspaper reporter repeatedly phones the unit seeking info and states, "it is the public's right to know that health status of elected officials." Which of the following actions should the nurse take? a. Acknowledge that the person is a client on the unit but give no specific details b. Refer any calls directly to the client's room so that the client and the family can decide what to tell the press c. Refer media inquires to the nursing supervisor d. Hang up on callers from the news media because the nurse is not required to speak to them

c. Refer the media inquires to the nursing supervisor

A nurse manager is participating in a root cause analysis following a sentinel event on her unit. Which of the following descriptions defines the purpose of a root cause analysis? a. A root cause analysis in preparing a legal defense for the event b. A root cause analysis estimates the costs involved in the event c.The root cause analysis investigates deviations from the standards of care surrounding the event

c. The root cause analysis investigates deviations from the standards of care surrounding the event

A nurse is caring for a pt who is dying and unable to make decisions for himself. The pt's adult children disagree on his code status. Which of the following sources should the nurse depend on for decisions regarding the clients end of life care? a. The pt's oldest child b. the attending provider c. the pt's health care proxy

c. the pt's health care proxy

Which task should the RN assign to the CNA during a code?

cardiac compressions

Five Rights of Delegation

right task, right circumstance, right person, right communication & right supervision

1.Saftey factors →↑ Risk of falls:

-History -↓ vision -impaired memory -house slippers -kyphosis (Hump back)

A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?

A middle adult male who is diaphoretic and reports epigastric pain

Which of the following indicates safe delegation?

A unit manager agrees to release a staff her unit to Unit B.The staff member she agrees to release is experienced on Unit B and is agreeable to the change. The unit manager's unit is fully staffed and patients are stable.

A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse plan to initiate?

Contact

A nurse is having difficulty reading the provider's writing when transcribing a prescription for a client's medication. Which of the following actions should the nurse take?

Contact the provider to clarify the prescription

A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of both of the nurses' clients while they are at lunch. The charge nurse is demonstrating which of the following types of conflict management?

Cooperating

Guides staff toward reaching an objective and shares responsibility with the staff. This is an ideal type of leadership because a great amount of creativity can occur and many strategies can be developed

Democratic

A nurse manager believes that a nurse is taking breaks that are too frequent and lengthy.

I understand you are allowed to take scheduled breaks during each shift, but you are taking more that the number allocated

47. A nurse is caring for a client who does not speak English. How should the nurse reinforce teaching regarding a colonoscopy?

Provide a hospital-assigned interpreter to relay medical information Rationale: Providing a hospital-assigned interpreter to relay medical information is the most appropriate means for communication. Interpreters should be available on call by phone or in person

A nurse is planning care for a 4-year old child who requires airborne precautions. Which of the following activities should the nurse plan for the child?

Putting a large puzzle together

30. Client is confused, combative, & requires jacket/wrist restraints. To prevent injury, which actions should the nurse take?

Remove the restraints and observe client's extremities for circulation every 4 hr Rationale: helps prevent nerve and musculoskeletal injuries as a result of poor circulation

12. A nurse received performance appraisal by unit manager. The unit manager should be reported to his supervisor about...

Verbal concerns provided by staff incorporated into data Rational: Only use data that has been formally documented

A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?

Wear a mask when providing care to the client

Right Supervision factors are:

supervise team member, be clear, monitor team member, provide feedback, intervene if necessary, evaluate client

A nurse is teaching an assistive personnel (AP) about caring for a client who has a do-not-resuscitate (DNR) order. Which of the following statements by the AP indicates an understanding of the teaching?

"I will call for the client's nurse to come to the room if I cannot detect the client's pulse."

A nursing unit is being educated on methods to prevent workplace violence from occurring on the nursing unit. Which statement by a nursing staff member indicates that adequate instruction has been provided?

"I will remain accountable for all of my behaviors and actions while working on the nursing unit."

25. Client undergoing hemodialysis who will be discharged. Which client statements most influence the current plan of care?

"My neighbor who takes me everywhere wrecked the car this morning." Rationale: clients requires transportation, communicate it to the interdisciplinary team, social worker may need to arrange transportation, the nursing staff will need to adjust teaching so client knows how to contact resources by phone

A nurse is delegating tasks for a group of clients to an assistive personnel (AP). Which of the following statements by the nurse provides the right direction of communication with the AP?

"Tell me what time the client in room 205 voids for the first time after his catheter is removed."

2. The manager is reviewing the accountability for client outcomes when delegating tasks AP(s). Which statement by the nurse is appropriate?

"The AP has no accountability for client outcomes when performing delegated tasks." Rationale: The nurse delegator remains accountable for patient outcomes when an AP has been delegated a task

4. Nursing support interdisciplinary collaboration:

-Open communication -Acknowledgement of knowledge & skills each member offers -Invitation of client/family to team meeting -request for referral

3. Nurse @ rehabilitation unit. Attends interdisciplinary meeting, client will be discussed (cervical spinal injury) Members include:

-Physical therapist -Occupational Therapist -Psychiatrist -nurse -vocational counselor -psychologist -Repertory Therapist

4.Morning blood glucose: 285 MG/DL; blood glucose before lunch 56 MG/DL; asymptomatic for hypoglycemia, Nursing Intervention:

-Recalibrate glucometer & recheck

8. Educational Foci for a new nurse:

-Skill proficiency -Assign to a preceptor -computerized charting -socialization into unit culture -facility policies/procedures

A charge nurse on a pediatric unit is delegating tasks to an assistive personnel who is pregnant and reports that she is unsure of her immune status

A 2 year old child who has impetigo contagiosa

5. A nurse is planning to assign obtaining V/S of postop client's → AP. She should assign obtaining for which clients?

A client who is 3 days postop following gastric bypass surgery Rationale: Client's physiologic status and stability of V/S; 3 days postop and his condition would have stabilized by this time

A charge nurse is making assignments for an oncoming shift. Which of the following clients should the charge nurse assign to a LPN?

A client who is disoriented and awaiting transfer to a long term care facility

45. The RN is preparing assignments for the day shift. Which clients should the nurse plan to assign to the licensed PN?

A client who is two days postop following a hip replacement Rationale: This is an appropriate client to delegate to the PN because client should be physically stable at this time

The RN must delegate care of an assigned client to a CNA for the shift. Which client would be best to delegate to the CNA?

A client who was transferred from the ccu 3 days ago and is ambulatory.

14. A LVN receiving report. Which clients should cause the nurse to request a change of assignment?

A client who will be started on TPN during the current shift Rationale: delivered through a jugular/subclavian vein. TPN contains a high concentration of dextrose, can → hyperglycemia (polydipsia, polyphagia, and polyuria) bring the assignment → attention of the scheduling/charge nurse, negotiate a new assignment. If no resolution, take the concern up the chain of command. If a no resolution, an unsafe staffing complaint (assignment despite objection (ADO) or document of practice situation (DOPS); Failure to accept is considered abandonment

A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?

A dependent adult admitted for the treatment of a spiral fracture

A charge nurse is talking with a staff nurse following a workshop on advance directives. Which of the following statements by the staff nurse demonstrates understanding of advance directives?

A family member of a client can have living will overturned in some cases

Examples of tasks nurses may delegate to a AP assistive personnel like CNAs

ADLs, bathing, grooming, dressing, toileting, ambulating, feeding (w/o swallowing precautions), positioning, bed making, specimen collection, I&O, vital signs for stable pts

7. Change of shift report & delegating tasks → AP. The nurse should tell the AP to perform which task first?

Blood glucose monitoring of a client who has a prescription for short acting insulin prior to breakfast Rationale: Timing of client's insulin and breakfast make this the priority, may → rapid change to client's condition

A new nurse witnesses an experienced nurse documenting an assessment on a patient-controlled analgesia (PCA) pump incorrectly on the computerized flow sheet. Which of the following should the new nurse do?

Bring to the nurse's attention that she is charting incorrectly and offer to demonstrate proper charting on the flow sheet

The most appropriate person to ask to place the leads back on the patient in 6D who is being monitored is:

CNA

The RN is utilizing the QSEN competencies to ensure quality of care for patients on a busy surgical unit. Which elements of the QSEN competency of teamwork and collaboration is essential to ensure implementation?

Care coordination

In which of the following situations would you, as the head nurse, be concerned about potential safety issues?

Carla, RN, has just ended a relationship with Jake, RN, and he will not leave her alone. You are meeting with Jake today because colleagues on nights have reported that Jake seems to have been intoxicated last night and the previous night.

The unit manager on the vascular unit is planning a change in the way post mortem care is provided. Which is the first step in the change of process?

Collect data

A charge nurse is assigning tasks to a RN, a licensed practical nurse (LPN), and an assistive personnel (AP). Which of the following tasks should the charge nurse delegate to the RN?

Complete the admission assessment

28. A nurse is collaborating on care for a client following a CVA. Which should be addressed by an occupational therapist?

Completing self-care Rationale: works with client to develop fine motor skills and coordination, such as improving hand strength

An RN is working on the surgical unit when a client who has abdominal pain is admitted. Which of the following activities must be performed by the RN?

Completing the client's initial admission assessment

A nurse is caring for a client that is preoperative. The nurse signs as a witness on the client's consent form. The nurse's signature on the consent form indicates which of the following?

Confirms the client appears competent to provide consent

8. A nurse may assign the AP to collect V/S on which clients?

Congestive heart failure, young adult client 1 dy postop following appendectomy, 2 dys postop laparoscopic cholecystectomy Rationale: newly admitted client w/asthmaticus (life-threatening episode of airway obstruction & is often unresponsive to common treatment) is not stable. A client receiving a continuous IV infusion of regular insulin for diabetic ketoacidosis (hyperglycemia and acidosis; results in severe dehydration.) is incorrect

A holistic nursing leader has multiple responsibilities on any given day. To prepare for delivering quality patient care, the nurse must first:

Consider self care needs.

A nurse is caring for a client who is in the bathroom. The nurse hears a loud thud and after opening the bathroom door, finds the client on the floor.

Determine level of consciousness

A nurse manager is planning staff development activities for the unit's new unlicensed assistive personnel

Determine the learning needs of the APs

Using quality monitoring tools, a facility committee identifies that clients who have congestive heart failure have an average length of stay this is 5 days instead of the established standard of 3 days

Determine which actions can be instituted to address this problem

The nurse is aware that what leadership responsibilities are important to all nurses? **Select all that apply.

Developing delegation skills Maintaining effective working relationships

7. What is a Clinical pathway or care map used to direct?

Direct/focus on client care

10. The nurse is participating in a performance improvement study of a frequently performed procedure. The most helpful in aid in improvement:

Incidences of complications R/T procedure Rational: Most reliant info regarding procedure

Based on recommendations following a regulatory agency visit, the nurse manager mandates a policy change. One of the staff members on the unit is resistant to the change

Encourage the nurse to verbalize reasons for resisting the change

54. A client expresses interest in learning more about advance directives. Which topics should the nurse anticipate discussing?

Enteral feeding tubes, Cardiopulmonary resuscitation, Durable power of attorney for health care Rationale: Organ donation is not part of; it includes living will

A charge nurse in an emergency department is making assignments for an assistive personnel for a shift with unexpected staff absences.

Escort clients from the emergency department to other areas of the facility for tests

A new graduate RN joins your unit. After a few weeks, she complains about some of her peers on the unit and compares their practices negatively to what she learned in her nursing program. She also is vocal about how she has learned so much here that she did not in her program. She is best described as:

Experiencing cultural marginality

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilites?

Explaining the operative procedure, risks, and benefits

During orientation of new nurse managers, the chief nursing officer stresses strategies that help nurse managers to achieve a powerful image. Which groups of behaviors best contribute to a powerful image for the nurse manager?

Greeting patients, families, and colleagues with a handshake and a smile; listening carefully when problems arise

The nurse leader is referencing the American Nurses Association nursing-sensitive quality indicators and knows that structure indicators include which element?

Hours of nursing care per patient

An assistive personnel (AP) tells the charge nurse that it is unfair that she has to take care of all the clients who are incontinent. Which of the following responses by the charge nurse is appropriate?

I delegate tasks to personnel based on their job descriptions

A nurse is caring for a child who has sustained extensive head injuries. The provider has diagnosed brain death.

I want to give you some information about an option that you have regarding donating your child's organs to others who are in need

A nurse is completing an incident report after administering an incorrect dose of medication to a client, even though the client experienced no ill effects from the error.

Identifies situations that contribute to the occurrence of medications errors

A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict?

Identify the problem

29. A nurse on a surgical unit receives a call from a client's neighbor who requests update. How should the nurse respond?

Inform the neighbor that you cannot give out any information about client Rationale: HIPAA

38. The informed consent was signed then states, "I have decided not to have the procedure." Which actions should be taken?

Inform the provider that client is withdrawing consent Rationale: Client has a right to refuse treatment

As the unit manager on the unit that is leading changes in heparin locks, you find that Elizabeth is very valuable in terms of her observation about other units and her knowledge of organization processes, and now in discussing the new procedure with others. Elizabeth might be considered an:

Informal change agent

The client is admitted to the ER with a third degree burn over the front legs. Which priority intervention should the RN implement?

Insert two large bore IV access routes.

The client is admitted to the ED with a third degree burn over the front of both legs, which is priority intervention should the nurse implement 1st?

Insert two large-bore IV access routes

2. Older adult with fall precautions found on floor. The most appropriate action is to...

Inspect for injuries Rational: First check for neck immobilization, get back in bed, contact HCP

The RN and the UAP enter the client's room and discover the client is unresponsive. Which action, according to the AHA guidelines, should the RN assign to the UAP first?

Instruct the UAP to get the crash cart

1. Preparing discharge of a CV Accident. Client has a gastrostomy tube. The nurse should check that...

Instructions are provided for eternal feedings at home

In a hospital setting, there appears to be conflict between two nurses, one who works in the emergency department and the other who works in the operating room. What type of conflict could be applied to this situation?

Interpersonal

Clinical incompetence is one of the more serious problems facing a nurse manager. Joyce, the nurse manager, is not aware of the problems of Sarah, a novice nurse. After she investigates, it is obvious that Sarah's peers are covering for her. Which of the following might Joyce include in her meeting with the nurses? (select all that apply)

Is is a nurses professional responsibility to maintain quality control , All instances of clinical incompetence are to be reported, It is not considered being disloyal when one nurse reports another for poor care, Patient care is the number one concern. Meeting standards is mandatory and necessary.

A home health nurse is caring for a client who asks what is included in a living will.

It allows the client to express personal wishes regarding health care decisions

Nurses at all levels of an acute care facility are preparing for a Joint Commission accreditation is necessary for what reason?

It guarantees that the organization has met Medicare certification standards

Clinical incompetence is one of the more serious problems facing a nurse manager. Joyce, the nurse manager, is not aware of the problems of Sarah, a novice nurse. After she investigates, it is obvious that Sarah's peers are covering for her. Which of the following might Joyce include in her meeting with the nurses? (select all that apply)

It is a nurse's professional responsibility to maintain quality control All instances of clinical incompetence are to be reported It is not considered being disloyal when one nurse reports another for poor care Patient care is the number one concern. Meeting standards is mandatory and necessary.

10. A nurse, acute care setting, planning care, beginning of the shift. Which tasks should the nurse assign to the AP?

Monitoring V/S of a client who had an appendectomy 12 hr ago Rationale: appropriate activity for the AP since it does not involve assessment, specialized knowledge or judgment

What theme do most definitions of critical thinking have in common?

Most critical thinking methods are both systematic and logical in nature

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority?

Move any clients in the immediate vicinity

A nurse enters a client's room and finds a fire has started. Number the following actions in the appropriate sequence that the nurse should follow.

Move the patient away from the fire, Activate the fire alarm, Shut the doors on the unit, and Extinguish the fire

A client in a long term care facility falls out of bed, fracturing his left hip. The side rails on the bed were not raised at bedtime

Negligence

The nurse manager is working to establish a culture of safety and knows that which element is the most important factor to its establishment?

No punishment is involved for reporting.

The nurse manager observes that the nursing staff on the unit who had previously undertaken the task of reviewing electronic documentation is not actively engaged in the process. Which part of the team development process is represented by the observations?

Norming

The female client diagnosed with pancreatic cancer has an advanced directive (AD) stipulating no CPR. Which intervention should Ms. Kathy implement first?

Notify the HCP about the AD

A nurse is making a client's bed and finds a capsule of medication in the sheets. Which of the following actions by the nurse is consistent with safe nursing practice?

Notify the provider of missed dose Complete a variance report Document the missed dose of medication on clients MAR

Which action would contribute to nurse fatigue in a staff nurse who is working a 12-hour shift on a medical unit and who has been assigned to take care of the five patients based on a primary care model?

Nurse eats lunch meal at the nurse's station while answering unit phone

According to the Institute of Medicine, which health care profession has been directly linked to patient safety?

Nurses

A group of nurses are working on an obstetrical unit and are discussing how the Nurses' Bill of Rights can be incorporated into the day-to-day operations of the nursing unit. Which suggestion could be implemented that would reflect compliance?

Nurses act as patient advocates

A nurse is preparing to give change of shift report to the oncoming nurse. Which of the following information should the nurse include?

Objective measurements about the client's condition

A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer

Observing a postoperative client who is confused.

1. AP reports → nurse that a client who returned → unit following an abdominal hysterectomy, dressing is saturated w/blood. Which tasks should be delegated to the AP?

Obtain V/S Rationale: The AP has been trained to and it is within the job description

The primary nurse in the critical care respiratory unit is very busy. Which nursing task should be the nurse's priority?

Obtain a tracheostomy tray for a client exhibiting air hunger

A nurse in the emergency department is preparing to obtain informed consent for surgery from a client who received meperidine hydrochloride IV during transport from a rural hospital

Obtain consent from a relative of the client

46. Which tasks could a nurse assign to AP?

Obtaining V/S on clients who are stable Rationale: When delegating, consider the acuity of client, education level & knowledge of the person receiving assignment

A nurse manager notices that Nathan, an RN who has been on the unit for approximately 3 years, has a particular interest in technology and seems to be very enthusiastic about working with software and hardware at home. She speaks with Nathan and asks him if he would lead investigation of software applications on the unit. This is an example of:

Opportunity

The 8 year old client diagnosed with vaso-occlusive sickle cell crisis is complaining of a severe headache. Which intervention should the RN implement first?

Orient the parents and child to the room

36. A nurse assisting with discharge plan, a permanent trachea. The nurse should verify the availability of which equipment?

Oxygen, Suction machine, Replacement cannula Rationale: nurse reinforces teaching S/S airway obstruction, CPR, and abnormal findings; standard: one same size, one smaller

Which of the following outlines the rights of individuals in health care settings?

Patient Care Partnership

Upon admission, a patient is given a copy of the rights of all patients and that health-care facility's policy and procedures to protect these rights. When asked by the patient the reason for this paperwork, the nurse replies that it is required by what governmental legislation?

Patient Self-Determination Act

A group of staff nurses are dissatisfied with the new ideas presented by the newly hired nurse manager. The staff wants to keep their old procedures, and they resist the changes. Conflict arises from:

Perceptions of incompatibility

A medical-surgical unit has added three new RN's to their night shift. Based on Brenner's novice to expert model and observations from the National Council of State Board of Nursing (NCSBN), what would the nurse manager expect to see from these new graduates nurses as they begin their orientation on the nursing unit?

Performance at a novice and/or advanced beginner level

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?

Performing hand hygiene before, during, and after direct contact with the client

26. Cerebrovascular accident (CVA, stroke). Which actions will prevent deep-vein thrombosis (DVT)?

Place sequential compression devices bilaterally Rationale: DVT = most common type of thrombophlebitis; Treated with rest, anticoagulant therapy, sequential compression devices (SCDs); SCDs prevent blood stasis by ↑ circulation, Measure: middle of the foot - below the knee or thigh, worn in bed

A staff nurse at a long-term care facility is evaluating an assistive personnel (AP) caring for a group of clients who require restraints. Which of the following is an appropriate action by the AP?

Placing the restraint tie on a moveable part of the bed frame

The matriarch of a family died on the vascular unit. The family tells the nurse the daughter is coming from a nearby city to see the body. Which intervention should the nurse implement?

Plan to allow the daughter to see the client in the room

The RN is preparing to ambulate the client with full-thickness burns on the lower extremities down the hall. Which priority intervention should the RN implement?

Put a gait belt around the client's waist.

An RN delegates the task of obtaining the blood pressure of a client who is 2 hr postoperative following a cholecystectomy to a licensed practical nurse (LPN). The LPN reports a blood pressure that is significantly higher than the client's previous reading. Which of the following actions should the RN take first?

Recheck client's BP

An RN delegates the task of obtaining the blood pressure of a client who is 2 hr postoperative following a cholecystectomy to a licensed practical nurse (LPN). The LPN reports a blood pressure that is significantly higher than the client's previous reading. Which of the following actions should the RN take first?

Recheck the client's blood pressure.

51. A nurse is obtaining blood samples for type and cross-match from two clients both scheduled for minor surgical procedures. Later, the nurse is convinced the labels were inadvertently switched. What is the appropriate action?

Redraw both specimens, label them carefully, and inform the blood bank of the error Rationale: assure client safety by redrawing, blood bank will be notified so the other two specimens can be discarded

A nurse is caring for a client who is a local public official. A local newspaper reporter repeatedly phones the unit seeking information and states, "it is the public's right to know the health status of elected officials." Which action should the nurse take?

Refer media inquiries to nursing supervisor

24. A nurse is providing pin site care to a client in skeletal traction. Which actions should prompt the charge nurse to intervene?

Removing the crust around pin sites during cleaning Rationale: Crusting at the pin site should not be removed because this provides a natural barrier from bacteria

9. A nurse is reviewing all occurrence reports submitted last month. She should identify that what should be reported?

Reports routinely omit the names of witnesses to the occurrence Rationale: A complete description of the occurrence should be included, along w/ names of any witness's → incident

The RN is caring for clients on a vascular unit. Which nursing task is most appropriate to delegate to the UAP?

Request the UAP to elevate the feet of the client who has chronic venous insufficiency

A nurse is caring for a client who asks for information about advance directives. Which of the following is an appropriate response by the nurse?

Your advance directive will take effect when you are unable to make health care decisions the client is able to accept or deny treatment as long as she is able to make informed decisions on her own

A nurse is ambulating a client who has an IV with an infusion pump

Turn the pump off

A nurse is making a client's bed and finds a capsule in the sheets. Which of the following actions by the nurse is consistent with safe nursing practice? Select all that APPLY a. administer the med to the client b. notify the provider of the missed dose c. complete a variance report d. document the missed dose of the med on the MAR e. place the med back in the med drawer

b. notify the provider of the missed dose c. complete a variance report d. document the missed dose of the med on the MAR

The staff working on the unit includes 4 RNs, 2 LPNs, and an NAP for 25 pts. What assignment is most appropriate for one of the LPNs? a. gather data about a newly admitted pt b. pass medications to a group of pts c. pass water to all of the pts on the unit d. obtain a urine sample from a Foley catheter on a pt who is not assigned to the LPN

b. pass medications to a group of pts Leadership and Management

A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation? (Select all that apply) a. right client b. right supervision and evaluation c. right direction and communication d. right time e. right circumstances

b. right supervision and evaluation c. right direction and communication e. right circumstances ATI Fundamentals ch 6

Right Person factors are:

assess and verify the team member's competence, review the team member's performance continually according to standards & take steps to remediate any failure to meet standards

Right Circumstance factors are:

assess the health status & complexity of care the client requires, match complexity of care demands to the skill level of each team member, consider the work load of the team members

A nurse is discussing with a newly licensed nurse about how to obtain informed consent from a client who is to undergo an epidural procedure.

autonomy

A nurse is caring for four clients who are scheduled for diagnostic tests.

cerebral arteriogram

Right Communication factors are:

communicate in writing, orally or both; be clear on data to collect, method and timeline, when to report concerns, specific tasks, expected results, timelines and expectations for follow up communication

A charge nurse on a ped unit is delegating tasks to an AP who is pregnant and reports that she is unsure of her immune status. Which of the following clients should the charge nurse assign to the AP? a. A 9 yr old child who has fifths disease b. A 4 yr old child who has varicella c. A 6 yr old child who has rubella d. A 2 yr old child who has impetigo contagiosa (impetigo)

d. A 2 yr old child who has impetigo contagiosa

A charge nurse receives a call from his nursing supervisor about an explosion at a local factory and an urgent need for facility beds for newly admitted clients. Which of the following clients should the nurse recommend for discharge? a. A 60 yr old client who has type 2 diabetes mellitus admitted 48 hr ago with uncontrolled glucose levels b. A 58 yr old client who is 12 hr post-op following a total knee arthoplasty c. A 80 yr old client admitted 24 hr ago for vomiting and diarrhea d. A 44 yr old client who has asthma and was admitted for carpal tunnel surgery

d. A 44 yr old client who has asthma and was admitted for carpal tunnel surgery

Examples of tasks nurses may delegate to a LPN (licensed practical nurse) like LVNs

monitor findings (as input to the RN's ongoing assessment), reinforce pt teaching from a standard care plan, perform tracheostomy care, suctioning, check NG tube patency, admin enteral feedings, insert urinary catheter, administer medications (except IVs meds)

A pt in long term care facility falls out of bed, fracturing his right hip. The side rails on the bed were not raise at bedtime, although this pt was a high fall risk. The nurse should identify what tort has occurred?

negligence

What tasks may RNs not delegate?

nursing process, client education, tasks that require nursing judgment

A registered nurse (RN) has delegated the administration of IV medications to a licensed practical/vocational nurse (LPN/LVN). Which statement accurately describes delegation? a. The RN must teach the LPN how to administer the IV medications. b. Ultimate responsibility for administering the medication lies with the LPN.. c. The RN is responsible for observing the LPN administer the IV medication d. The RN is the one accountable for the quality of care that the patient receives.

d. The RN is the one accountable for the quality of care that the patient receives. MS ch 1

A new graduate nurse is assigned a pt who is 2 days postoperative who has had a colostomy. The pt has an order to have an NG tube inserted immediately. The new graduate has never inserted this type of tube in a pt. How should the new graduate nurse proceed in this situation? a. delegate the task to a NAP b. read over the procedure and then insert the tube c. notify the practitioner of the new graduate's inexperience d. ask an experienced RN for assistance with the procedure

d. ask an experienced RN for assistance with the procedure Leadership and Management

Based on recommendation following a regulatory agency visit, the nurse manager mandates a policy change. One of the staff nurses on the unit is resistant to the change, and the nurse manager notes that the nurse does not deliver care according to the new policy. Which of the following actions should the nurse take? a. explain the disciplinary consequences of not implementing the new policy b. reinforce with the staff nurse the importance of implementing the policy change c. ignore the resistance d. encourage the nurse to verbalize reasons for resisting the change

d. encourage the nurse to verbalize reasons for resisting the change

A nurse is caring for several clients who require diagnostic testing and is delegating tasks to an AP. Which of the following tasks should the nurse direct the AP to perform FIRST? a. change the transparent dressing on a pt who has a stage 2 pressure ulcer b. bring a pitcher of fresh water to a pt who has just had a lumbar puncture c. transport a pt to the radiology department for a routine chest x-ray d. take an arterial blood gas specimen to the lab

d. take an arterial blood gas specimen to the lab

A nurse is working with an AP in a long term care facility. According to the five rights of delegation, which of the following determinations should the nurse make prior to assignment of tasks? a. whether the AP has consented to the performance of delegated tasks b. the client's willingness to consent to the care of the AP c. whether the task can be more efficiently completed by the nurse d. the degree of supervision that the AP will require to complete the task

d. the degree of supervision that the AP will require to complete the task

A nurse is ambulating a client who has an IV with an infusion pump. Upon returning to the client's room and plugging the infusion pump in, the client reports a slight tingling in his hand. Which of the following actions should the nurse take? a. plug the pump into a different outlet b. place a service tag on the pump for a routine inspection c. unplug the pump and plug it back into the same outlet to see if the sensation of tingling is repeated d. turn the pump off

d. turn the pump off

A nurse is delegation the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply) a. the roommate ambulates independently b. the client ambulates with his slippers on over his antiembolic stockings c. the client uses a front-wheeled walker when ambulating d. the client had pain medication 30 min ago e. the client is allergic to codeine f. the client ate 50% of his breakfast this morning

b. the client ambulates with his slippers on over his antiembolic stockings c. the client uses a front-wheeled walker when ambulating d. the client had pain medication 30 min ago ATI Fundamentals

A nurse on a med surg unit is caring for a group of pts. For which of the following situations should the nurse complete a variance report? a. clarification of a med dose prescribed by the provider b. the discovery that a pre-op client has received and eaten breakfast

b. the discovery that a pre-op client has received and eaten breakfast

a principle that is based on the assumption that one person can assume responsibility for making the decisions for another person

paternalism

Based on the principle that actions should be taken with the intent to do good. It is associated with nonmaleficence, which is the requirement that health care providers do no harm to their clients.

beneficence

9. A nurse is preforming a performance improvement study for patient controlled analgesia (PCA). The nurse should...

bring it to the nurses' attention that she is documenting incorrectly & Offer assistance. Rational: If this does not work, contact nurse manager

Who is responsible for educating the health care team in an organization on the policies, practices, and laws of delegation? a. American Nurses Association b. National Council of State Boards of Nurses c. health care organization d. the state

c. health care organization Leadership and Management

A nurse is preparing to give change of shift report to the oncoming nurse. Which of the following info should the nurse include? a. routine care procedures b. biographical info c. objective measurements about the client's condition

c. objective measurements about the client's condition

When a nurse considers delegating a task, what 5 rights should be utilized? a. right pt, right chart, right physician, right results, right information b. right person, right pt, right task, right documentation, right time frame c. right task, right circumstance, right person, right direction/communication, right supervision d. right room, right time, right person, right documentation, right directions

c. right task, right circumstance, right person, right direction/communication, right supervision Leadership and Management

The nurse has become incredibly busy with discharging 2 pts and expecting a new pt any second. The following are tasks that need to be completed right away. What task can the nurse delegate to an NAP to help out with managing the nurse's time with pts? a. remove sutures from an incision and apply dressing to the pt's left wrist b. provide tracheostomy care to the pt c. sit with a pt who was recently diagnosed with Crohn's disease and is crying d. transport a pt to x-ray on a cardiac monitor

c. sit with a pt who was recently diagnosed with Crohn's disease and is crying Leadership and Management

A charge nurse is observing a group of new RNs. Which of the following observations should the charge nurse report to the nurse manager as a violation of HIPAA? a. assigning a client who requested a private room to a semi private due to unavailability b. placing a client who is confused in restraints c. talking about clients with other nurses in the cafe

c. talking about clients with other nurses in the cafe

48. Planning to use SBAR communication tool when calling a provider. Which statement is appropriate for the "B" step?

"Client was found unconscious on the floor in her home." Rationale: This statement is the Background or context of the situation in the SBAR tool

The culture of blame and punishment or errors tends to encourage a culture of:

Perfectionism

2.Incident Reports:

-Description of -Confidential -Incident/Actions taken -Risk mngmt investigations

3.Pulling a client up in bed with a draw sheet: Where should the nurse face?

-Direction that the client is moving

5.Appropriate actions if severe weather code activated:

-Draw shades, close drapes -Ambulatory pts → hallway -Turn weather radio on

In delegating to a CNA in a home health setting, which of the following represents the most appropriate delegation communication?

"Mrs. S needs help getting into and out of her bathtub. Her bath will need to be completed by 10:00 When you are helping her to dry, please check between her toes and toenails, and phone me by 10:30 if you notice nail discoloration or redness

What task should be delegated to the CNA?

b. Clean up the patient (ESRD) in 6G who was incontinent

5. Prep discharge, acute care facility → LTC, Info for discharge includes:

-History of coexisting & current illness -Level of functional abilities -Summary of physical, occupational, speech therapy W/treatment goals -Description of bladder/bowl plan W/ education provided -Stat upon discharge, mode of transportation, accompanies

13. Listening → report. Which statement indicates the nurse should assume TPC rather than assigning tasks to the AP?

"Client's BP and pulse have been unstable." Rationale: To promote client safety, the more stable clients should be chosen when delegating tasks to APs

55. A nurse is orienting a group of new grad nurses and explains purpose of delegation. Which is an appropriate statement?

"Delegation permits a designated individual to meet a goal on your behalf." Rationale: Delegation is defined as directing the performance of others to accomplish goals of the nurse and the facility.

A nurse is teaching a group of newly hired nurses about the requirements for disaster planning. Which of the following statements by one of the newly hired nurses indicates an understanding of the teaching?

"Disaster drills should be held on a regular basis."

27. Assigned client care activities to AP. Which statement by the AP indicates a need for assistance in establishing priorities?

"I have my assignment and will start with room 1, then work my way to room 10." Rationale: The AP's statement does not include consideration of the tasks that need to be performed for each client

The nurse leader has assembled a team to develop a plan to decrease the number of patient falls on the unit. Which statement by a team member is the best example of an exemplary follower?

"I have noticed that the last few patients who fell were experiencing dementia. What if we focused on those patients first?"

A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict?

"I need to talk to you about unit expectations regarding delegating and completing tasks

19. Client is semicomatose; client's son reports the family does not want any heroic measures. How should the nurse respond?

"I will verify the status of the advance directives." Rationale: Advance directives are initiated by client while competent to identify health care wishes. Minimizes ethical dilemmas

A nurse manager observes a newly licensed nurse and an assistive personnel (AP) arguing about the failure of the AP to restock unit supplies. The AP leaves the room. Which of the following is an appropriate statement at this time by the nurse manager to the newly licensed nurse?

"I would like for you to approach the AP to resolve the problem."

A nurse manager is reviewing the Good Samaritan law with a group of newly licensed nurses. Which of the following statements by the nurses manager is appropriate?

"If you render aid in an accident, do not leave the scene until another competent person can take over."

40. A nurse is reinforcing teaching to the AP to set limits on a client's manipulative behavior after the nurse has reviewed the APs performance of a delegated task. Which responses by the AP indicate further teaching is needed?

"The goal for client is to ask directly for what he wants." Rationale: Eval of performance should focus on how the AP completed the task, not an eval of client outcomes

37. A nurse is caring for a client who is pregnant & refuses to receive chemo. Which is the best response for the nurse to give?

"This must be a difficult decision for you." Rationale: Therapeutic communication techniques encourage open, honest communication

Prior to delegating client care, nurses should consider the:

--Predictability of the outcome: Will the completion of the task have a predictable outcome? Is it a routine treatment? Is it a new treatment for that client? --Potential for harm Is there a chance that something negative could happen to the client (bleeding, aspiration)? Is the client unstable? --Complexity of care Does the client's care require complex tasks? Does the state's practice act or the facility's policy allow the delegatee to perform the task, and does she have the necessary skills? --Need for problem solving and innovation Is judgment essential while performing the task? Does it require nursing assessment or data‑collection skills? --Level of interaction with the client: Does the delegatee need psychosocial support or education during the performance of the task?

Nursing Interventions

--Provide supervision, either directly or indirectly (assigning supervision to another licensed nurse). --Monitor performance. --Intervene if necessary (for unsafe clinical practice). --Provide feedback: Did the delegatee complete the tasks on time? Was the delegatee's performance satisfactory? Did the delegatee document and report unexpected findings? Did the delegatee need help completing the tasks on time? --Evaluate the client and determine the client's outcome status. --Evaluate task performance and identify needs for performance‑improvement activities and additional resources.

20. A nurse is planning to assign care activities → AP. Which activities are appropriate for assignment?

-Accompanying a client with depression to occupational therapy -Checking the position of a client in soft wrist restraints -Sitting with a client who abuses alcohol whose last drink was two days ago Rationale: anything that requires special knowledge is not in the scope of practice

2.Total hip arthroplasty, confused, moving leg into positions that could dislocate, what are your nursing interventions?

-Arm/Leg restraints immediately -Order from HCP -Family member sign for restraints

3.If a person at the nursery does not have the code, the appropriate intervention is to...

-Ask them to get the code from the mother

1. Change of sift report at 7:00, Clients are to be seen in the order of...

1)Blood transfusion @ 0400 (infusion should not last longer than 4HRS) 2)Needs rapid onset insulin before 0800 trays 3)Analgesics QID PRN, last @ 0430 4)Colposcopy @ 1130, informed consent needs verification 5)Discharging today, needs reinforcing R/T dressing change (not time sensitive)

4.Preparing to insert IV catheter, morphine sulfate 10mg IV Bolus, number the time management principles:

1)Notify staff she will be unavailable 2)Envision procedure when collecting supplies 3)Draw up morphine before entering room, then admin immediately after IV established 4)Enter room, hang hygiene 5)Explain procedure, prep client

A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks certified nursing assistants (CNAs) may perform, which of the following client activities should she include? Select all that apply: 1. Bathing 2. Ambulating 3. Toileting 4. Determining pain level 5. Measuring vital signs

1. Bathing 2. Ambulating 3. Toileting 4. Measuring vital signs -determining pain level is a task that requires the assessment skills of licensed personnel, it is outside the scope of practice of a CNA ATI Fundamentals ch 2

A registered nurse (RN) is providing care to a patient who had abdominal surgery 2 days ago. Which task is appropriate to delegate to the nursing assistant? 1. Helping the patient ambulate in the hall 2. Changing surgical wound dressing 3. Irrigating the nasogastric tube 4. Providing brochures to the patient on health diet

1. Helping the patient ambulate in the hall Fundamentals text ch 21

The unit is very busy and short staffed. What could the RN delegate to the unlicensed assistive personnel (UAP)? 1. Administer antihypertensive meds to stable patients 2. Obtain orthostatic BP readings for older patients 3. Check BP readings for the patient receiving IV sodium nitroprusside 4. Teach about home BP monitoring and use of automatic BP monitoring equipment

2. Obtain orthostatic BP readings for older patients -UAPs can't administer meds -pt on sodium nitroprusside is having a hypertensive crisis, needs an RN -only RNs can do the teaching about at-home BP MS workbook ch 32

The nurse would delegate which of the following to nursing assistive personnel (NAP)? (Select all that apply.) 1. Repositioning and retaping a patient's nasogastric tube 2. Performing glucose monitoring every 6 hours on a patient 3. Documenting PO intake on a patient who is on a calorie count for 72 hours 4. Administering enteral feeding bolus after tube placement has been verified 5. Hanging a new bag of enteral feeding

2. Performing glucose monitoring every 6 hours on a patient 3. Documenting PO intake on a patient who is on a calorie count for 72 hours Fundamentals text ch 45

Which of the following tasks should the charge nurse delegate to an experienced LPN working on the adult medical unit? 1. Teaching a client about the preprocedure preparation for a gastric endoscopy 2. Inserting an NG tube for gastric acid analysis 3. Administering IV midazolam hydrochloride during endoscopy 4. Developing a nursing care plan for a client having a cystoscopy

2. Inserting an NG tube for gastric acid analysis -NG tube insertion is included in LPN education and is an appropriate task for an experienced LPN -the other options are part of the RN scope of practice Critical Thinking textbook

A nurse manager of a medical-surgical unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which of the following staff members should the nurse assign this client? 1. Charge nurse 2. RN 3. Practical nurse (PN) 4. Assistive personnel (AP)

2. RN -a client returning from surgery requires an RN's assessment and establishment of a plan of care, especially if the client is potentially unstable ATI Fundamentals ch 6

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)? 1. A client requiring a colostomy irrigation 2. A client receiving continuous tube feedings 3. A client who requires urine specimen collection 4. A client with difficulty swallowing food and fluids

3. A client who requires urine specimen collection -colostomy irrigations and tube feedings are not performed by UAPs because these are invasive procedures -the client with difficulty swallowing is at risk for aspiration NCLEX ch 7

The nurse employed at a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and 3 unlicensed assistive personnel (UAP) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse? 1. A client who requires a bed bath 2. An older client requiring frequent ambulation 3. A client who requires hourly vital sign measurements 4. A client requiring abdominal wound irrigations and dressing changes every 3 hours

4. A client requiring abdominal wound irrigations and dressing changes every 3 hours -bed bath, assisting with ambulation, and vital signs can all be performed by UAPs NCLEX ch 7

11. There is a threat of flooding, and an internal disaster plan activated. Which should the nurse evacuate first?

A client receiving antibiotic IV therapy and wound vacuum care Rationale: medically stable but will require treatment following transport to another facility

An RN is making assignments for a practical nurse (PN) at the beginning of the shift. Which of the following assignments should the PN question? 1. Assisting a client who is 24-hr postoperative to use an incentive spirometer 2. Collecting a clean-catch urine specimen from a client who has a wound infection 3. Providing nasopharyngeal suctioning for a client who has pneumonia 4. Teaching a client who has asthma how to use a metered-dose inhaler

4. Teaching a client who has asthma how to use a metered-dose inhaler -the RN is responsible for primary teaching, the PN may only reinforce teaching -the other options are within the scope of practice of a PN ATI Fundamentals ch 6

3. What is the normal oxygen saturation?

90-100%

Which task is appropriate for a registered nurse (RN) to delegate to a nursing assistant? 1. Explaining to the patient the preoperative preparation before the surgery in the morning 2. Administering the ordered antibiotic to the patient before surgery 3. Obtaining the patient's signature on the surgical informed consent 4. Helping the patient to the bathroom before leaving for the operating room

4. Helping the patient to the bathroom before leaving for the operating room Fundamentals text ch 21

When creating an assignment for a team consisting of an RN, 1 LPN, and 2 UAPs, which is the best client for the LPN? 1. a client requiring frequent temperature checks 2. a client requiring assistance with ambulation every 4 hrs 3. a client on a mechanical ventilator requiring frequent assessment and sunctioning 4. a client with a spinal cord injury requiring urinary catheterization every 6 hrs

4. a client with a spinal cord injury requiring urinary catheterization every 6 hrs -UAPs can do temperature checks and ambulation -the pt on the mechanical ventilator requiring frequent assessment and suctioning should be more appropriately cared for by the RN -urinary catheterization is within LPN's scope of practice NCLEX

34. A charge nurse is delegating meal assistance after delivery of the dinner trays. Delegate which clients to the AP?

A client who has Parkinson's disease Rationale: The charge nurse should delegate meal assistance for client who has Parkinson's disease to the AP

A nurse is reviewing the medication administration records from the previous shift. Which of the following findings should indicate to the nurse a need for an incident report?

A client received a crushed bupropion XL tablet mixed with applesauce

A nurse in an emergency department is caring for four clients

A child who was left unsupervised for several hours at home and is being treated for a fractured leg

21. A child admitting following an appendectomy is to be placed in a room with what other client?

A child with type 1 diabetes Rationale: The greatest risk to client following surgery is from infection. Both requires monitoring & teaching

3. A nurse is assigned a group of clients at the start of the shift. Which clients should the nurse plan to see first?

A client asking about his PCA pump which contains morphine Rationale: Using the priority (urgent vrs. Nonurgent) pain mngnt due to acute illness/injury = high priority

33. Listening to report on assigned clients at the beginning of the shift. Which information establishes a priority for the nurse?

A client had a catheter removed 7 hr ago and has not voided Rationale: urgent vs. nonurgent, he has not voided for 7 hours

the right to self determination, independence, and freedom of choice

Autonomy

11. A nurse noticed that the unit manager does not intervene when there is a conflict between team members. The conflict resolution she is using is...

Avoiding/Withdrawing

A charge nurse is evaluating conflict resolution between two staff nurses

Accommodation

A nurse is preparing to provide discharge teaching to an older adult client. Which of the following teaching considerations should the nurse include?

Allow frequent rest periods during teaching

A charge nurse is planning care for a group of clients. Which of the following tasks should be delegated to an assistive personnel (AP)? (Select all that apply.)

Ambulating Client with a Walker Adding thickener to liquid on food tray

In the past year, you have noticed an increase in patient falls on your unit. In reading studies related to staffing and patient outcomes, you realized that you will need to plan for:

An increased number of RN positions

A nurse manager of a medical‑surgical unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which of the following staff members should the nurse assign this client? A. Charge nurse B. RN C. Practical nurse (PN) D. Assistive personnel (AP)

Answer= B A. Although the charge nurse can provide all the care this client requires in the immediate postoperative period, administrative responsibilities might prevent the close monitoring and assessment this client needs. B. CORRECT: A client returning from surgery requires an RN's assessment and establishment of a plan of care, especially if the client is potentially unstable. C. Although PNs can perform some of the tasks crucial in the immediate postoperative period, they cannot provide the comprehensive care this client needs at this time. D. Although APs can perform some of the tasks crucial in the immediate postoperative period, they cannot provide the comprehensive care this client needs at this time, particularly assessment.

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply.) A. The roommate ambulates independently. B. The client ambulates with his slippers on over his antiembolic stockings. C. The client uses a front‑wheeled walker when ambulating. D. The client had pain medication 30 min ago. E. The client is allergic to codeine. F. The client ate 50% of his breakfast this morning.

Answer= B, C, D A. The AP does not need to know the status of the client's roommate to complete this assignment. B. CORRECT: To complete this assignment safely, the AP should make sure the client wears stockings and slippers. C. CORRECT: To complete this assignment safely, the AP should make sure the client uses a front‑wheeled walker. D. CORRECT: To complete this assignment safely, the AP should know that the client should be feeling the effects of the pain medication. E. The AP does not need to know the client's allergy status to complete this assignment. F. The AP does not need to know the client's food intake to complete this assignment.

A nurse is preparing an in‑service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? (Select all that apply.) A. Right client B. Right supervision and evaluation C. Right direction and communication D. Right time E. Right circumstances

Answer= B, C, E A. The right client is one of the rights of medication administration, not of delegation. B. CORRECT: The right supervision and evaluation is one of the five rights of delegation. They also include the right task and the right person. C. CORRECT: Right direction and communication is one of the five rights of delegation. They also include the right task and the right person. D. Although the delegatee needs to know whether there is a time frame or a specific time to perform the task, the right time is not one of the five rights of delegation. It is one of the rights of medication administration. E. CORRECT: The right circumstances is one of the five rights of delegation. They also include the right task and the right person

A nurse on a medical‑surgical unit has received change‑of‑shift report and will care for four clients. Which of the following client's needs should the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hr ago with aspiration pneumonia B. Reinforcing teaching with a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer

Answer= C A. It would be inappropriate to delegate the feeding of a client who has aspiration pneumonia to an AP because the client is at risk for further aspiration. B. Either an RN or an PN, not an AP, may reinforce teaching. C. CORRECT: The application of a condom catheter is a noninvasive, routine procedure that the nurse may delegate to an AP. D. Either an RN or an PN, not an AP, may apply a sterile dressing.

An RN is making assignments for a practical nurse (PN) at the beginning of the shift. Which of the following assignments should the PN question? A. Assisting a client who is 24‑hr postoperative to use an incentive spirometer B. Collecting a clean‑catch urine specimen from a client who has a wound infection C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered‑dose inhaler

Answer= D A. Assisting a client to use an incentive spirometer is within the scope of practice of the PN. B. Collecting a clean‑catch urine specimen is within the scope of practice of the PN. C. Providing nasopharyngeal suctioning is within the scope of practice of the PN. D. CORRECT: The RN is responsible for primary teaching. The PN may only reinforce teaching.

7. Report: LVN reports to RN that a new AP has not totaled I&O. The RN then should...

Ask AP if he would like help Rational: The AP is new and may need help

The RN is caring for a client diagnosed with full thickness burn over the right lower extremity. Which task should the RN delegate to the UAP?

Ask the UAP to cleanse the client's dentures and place in a container.

A nurse is working with an assistive personnel who appears to be under the influence of alcohol during the night shift.

Ask the nursing supervisor to observe the AP and validate the nurse's suspicion

A charge nurse is delegating tasks on a nursing unit that is short staffed. A client has a prescription for a wound irrigation twice a day. Which of the following actions should the charge nurse take?

Assign the procedure to a licensed practical nurse (LPN).

A charge nurse is delegating tasks on a nursing unit that is short staffed. A client has a prescription for a wound irrigation twice a day. Which of the following is an appropriate action for the charge nurse to take?

Assign the procedure to the LPN

A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of over-delegation?

Assigning the most efficient AP to perform glucometer monitoring for each client

44. A nurse is organizing care for a group of clients. Which tasks could the nurse assign to the AP?

Assist a client who is 1 day postop following an appendectomy and requesting a bedpan Rationale: The AP should provide care to stable clients. Assisting a stable client with ADLs is appropriate for the AP

A nurse is delegating a task to an assistive personnel. The AP is to transfer a client who has a below the knee amputation from a bed to a wheelchair.

Assist the Ap after he has practiced the transfer.

31. A nurse is planning care for a client who has anorexia nervosa. Which client goals have the highest priority?

Attain a weight that is greater than the 75th percentile for age and height Rationale: Maslow's hierarchy of needs, meeting the physiological need for adequate nutrition is the priority client goal

A group of providers are participating in a cardiopulmonary resuscitation effort for a client who is in cardiac arrest.

Autocratic

A nurse requests a schedule change due to a family issue. The nurse manager states, "You cannot change the schedule without going through the staffing office" The NM is demonstrating what type of leadership style?

Autocratic

Makes decisions independently and then notifies staff of the decisions made. Maintains a high degree of control over the staff and allows little freedom of staff members

Autocratic

Nursing management observes team members picking up assignments from others in order to complete the designated task. How would the nurse manager categorize this action?

Backup behavior

A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts?

Battery

. A unit manager watches a new RN graduate interacting with a patient. When the RN comes out of the room, the unit manager says, "I don't know what they taught you in your nursing program, but if I see you do that again, I will write you up." This example demonstrates:

Coercive use of power

23. A newly licensed nurse is planning to delegate tasks to an AP. Which tasks should the nurse plan to perform?

C. Observing a client's sacrum for edema Rationale: Observation is a data collection technique & requires specialized knowledge

15. A nurse is performing CPR on an adult who has suffered cardiac arrest at the grocery store. The nurse understands that the Good Samaritan law provides civil immunity if the nurse...

Certified in CPR and basic life support Rationale: Immunity when performing in an emergency situation

A nurse is caring for a client who received a sedative hypnotic medication at bedtime. The client gets out of bed and falls, sustaining a laceration that requires suturing

Client found sitting on the floor with 3 cm laceration above left eyebrow. Oriented to name only. Provider notified.

16. A nurse is implementing care for a client based on a clinical pathway. Which principles should the nurse follow?

Clinical pathways never replace clinical judgment Rationale: Clinical pathways (care plans, agency guidelines, or care maps) are designed to provide the standard, reduce mistakes, improve outcome and quality of care, and decrease duplication of effort, not all clients respond in the same way

43. A nurse is caring for a client who requires catheterization for a urine specimen. Client tells the nurse that she is concerned about her privacy during the procedure. Which actions should the nurse take to alleviate client`s concern?

Close the door and assure client that she will be covered Rationale: Client has expressed her concern for privacy, verbal and nonverbal communication

A charge nurse is planning client care assignments for the unit. Which of the following clients should the nurse assign to a licensed practical nurse (LPN)?

Crohn's disease and requires enteral feedings

32. Which clients would benefit from an interdisciplinary client care conference? A client who is admitted with a diagnosis of...

Cystic fibrosis Rationale: thick, sticky mucus; R/F respiratory infections, intestinal obstruction, poor growth, malnourishment, cirrhosis of the liver, osteoporosis, and DM; Life expectancy ↓; Management is complex and requires a lifelong multidisciplinary approach

At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN?

D. Inserting a nasogastric tube for a client

Which task should a LPN questions that was delegated by a RN? A. assists a pt 24 hr postop to use an IS B. collect a clean-catch urine specimen from a pt who was admitted on the previous shift C. provide nasopharyngeal suction for a pt with pneumonia D. replace the cartridge and tubing on a PCA pump

D. RN is responsible for PCA pump maintenance

18. A nurse asks the AP to take a specimen to the lab & AP refuses. Which action should the nurse take?

Discuss the incident with the AP Rationale: Reviewing the incident with the AP allows the nurse to understand the AP's perspective

42. Which actions jeopardize client confidentiality?

Discussing clients in the cafeteria, verbal report outside clients room, written report sheet into the hospital trash Rationale: HIPPA

6. Complete dressing change. During the change of shift report the new nurse would like a demonstration. The appropriate intervention for the nurse giving report is to...

Give report in conference room, then dressing change in client room

All nurses are leaders in patient health care primarily because they:

Know the patient the best

A nurse manager is coordinating staff assignments for RNs and licensed practical nurses (LPNs) following a local disaster. Which of the following is an appropriate assignment by the nurse manager to provide safe and effective client care?

LPNs provide care to green tags

A nurse requests a schedule change due to a family issue. The nurse manager states, "Find someone to switch with you." The NM is demonstrating what type of leadership style?

Laissez-faire

The nurse administrator is aware that the 1984 death of a college student from a drug-drug interaction resulted in what standard of medical care?

Limitation to the number of hours a resident in training may work

Which action by a nurse manager would be viewed as a barrier to change in the clinical setting?

Limiting communication among members of staff

10. The nurse manager knows that what is the most important focus of a culture of safety?

Looking at the reason for an error

As a new leader in a 40-bed step down unit, Jane desires to make an impact on the nurses, patients and families. In order to survive and thrive as a leader, she knows that she must do which of the following? (Select all)

Maintain a positive attitude, Listen to constituents, Maintain balance, Generate self-motivation, Build self-confidence

A charge nurse is evaluating a newly licensed nurse at the end of orientation. Which of the following behaviors indicates the nurse is using effective time management skills?

Makes a list of non essential tasks to be performed later

Which statement is inaccurate with regard to leading and managing teams?

Management personnel must assume team leadership positions

A nurse has four client assignments on a maternal newborn unit. Which of the following tasks can be delegated to an assistive personnel (AP)?

Measure output of mother's 1st voiding

A nurse in an emergency department receives report from an emergency responder who states a client is being transported following exposure to a "dirty bomb." The nurse should prepare to care for a client that has been exposed to which of the following types of agent?

Radiologic

A nurse is reviewing safe use of a wheelchair with a group of assistive personnel. Which of the following should the nurse include?

Raise foot plates on wheelchair prior to transferring

A nurse is reviewing safe use of a wheelchair with a group of assistive personnel. Which of the following should the nurse include?

Raise the footplates of the wheelchair before transferring the client.

5. Charge nurse is making assignments. The nurse should consider...

Retaining care activities that only an RN can delegate other activities as appropriate

17. A charge nurse has assigned a group of clients to a newly licensed LVN. The charge nurse observes the LVN chatting sociably with peers, left the unit without communicating, reports from clients about lack of care. Which is an appropriate action?

Review the LPN's assignment in relation to other nurses on the unit Rationale: Reviewing the LVNs assignments, allows the charge nurse to see the delegated task from the LVNs perspective

The RN is preparing for an initial visit to a client diagnosed with CHF. Which intervention should the RN implement first?

Review the client's referral form/pertinent data.

41. A nurse checks w/personnel through the day to determine if they are completing tasks. What right of delegation?

Right supervision Rationale: the right supervision when she assesses how the tasks are being accomplished and if any improvements are needed

A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step?

The client was found unconscious on the floor in her home

Which client requires the immediate attention of the intensive care nurse

The client with acute respiratory distress syndrome (ARDS) who is having difficulty breathing

A nurse is working with an assistive personnel in a long term care facility. According to the five rights of delegation, which of the following determinations should the nurse make prior to assignment of tasks?

The degree of supervision that the AP will require to complete the task

The nurse is sharing information received during a patient interview with different health-care providers. In which of these interactions does the nurse breach the patient's confidentiality?

The nurse discusses the patient's marital difficulties with nurse's from another unit

A nurse is delegating a client care task to an assistive personnel. Which of the following directions should the nurse give the AP?

This client needs to ambulate using a waker three times today

A nurse requests a schedule change due to a family issue. The nurse manager states, "Let's develop a system to be proactive for all the staff when things like this happen." The NM is demonstrating what type of leadership style?

Transformational

A nurse manager is coordinating staff assignments for RNs and licensed practical nurses (LPNs) following a local disaster. Which of the following is an appropriate assignment by the nurse manager to provide safe and effective client care?

Treatment milestones When developing a critical pathway, the nurse should include time bound activities, interventions, and outcomes for clients who have a common diagnosis; therefore, include treatment milestones facilitates standardizing care

In 2003, the IOM published a report emphasizing competencies of health care professionals. Which of the following is (are) integral to promoting a safe health care environment? (select all that apply) :

Utilize informatics, Provide patient-centered care, Work in interdisciplinary teams, Employ evidence-based practices, Apply quality improvement

During staff meetings, you make it a regular practice to encourage shared problem solving and to recognize those who go to beyond basic roles and responsibilities to contribute to a positive team environment and to quality patient care. This practice exemplifies:

Values-based management

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first?

Wash the site of injury with soap and water

You overhear a newly graduated RN telling one of your colleagues that leadership and management belong to the unit manager and not to her. As a nursing colleague, you respond by demonstrating understanding that the perception of the new graduate:

Would benefit from further understanding of her role as a professional, whose influence may affect the decision making of patients, colleagues, and other professionals.

When caring for a patient with Alzheimer's disease, which task could be delegated to the LPN/LVN on the team? a. Administer enteral feedings via a gastrostomy tube. b. Teach patient and caregivers memory enhancement aids. c. Use bed alarms and frequent monitoring to decrease fall risk. d. Make referrals for community services such as adult day care.

a. Administer enteral feedings via a gastrostomy tube. MS ch 59

A nurse is caring for four clients who are scheduled for diagnostic tests. For which of the following tests should the nurse obtain written consent from the client? a. Cerebral arteriogram b. MRI c. CT scan

a. Cerebral arteriogram (because it is an invasive procedure)

A nurse is caring for a pt who received a sedative-hypnotic med at bedtime. The pt gets out of bed and falls, sustaining a laceration that requires suturing. Which of the following statements should be included as part of the nurse's documentation in the chart? a. Client found sitting on the floor with 3 cm laceration above left eyebrow. Oriented to name only. Provider notified b. Client found sitting on the floor with blood running down face. Side rails had not been raised by the AP when the client was placed in bed

a. Client found sitting on the floor with 3 cm laceration above left eyebrow. Oriented to name only. Provider notified

A nurse manager believes that a nurse is taking breaks that are too frequent and lengthy. Which of the following is an assertive statement that the charge nurse should use to initiate discussion of the issue? a. I understand that you are allowed to take scheduled breaks during each shift, but you are taking more than the number allocated. Let's set a time when we can discuss this behavior b. you are taking more breaks during each shift than hospital policy allows. You will need to take only the number of breaks specified and be sure you are back on time

a. I understand that you are allowed to take scheduled breaks during each shift, but you are taking more than the number allocated. Let's set a time when we can discuss this behavior

A nurse is delegating a client care task to an AP. Which of the following directions should the nurse give the AP? a. This client needs to ambulate using a walker three times today b. Please record strict I & O for this client

a. This client needs to ambulate using a walker three times today

An RN on a medical-surgical unit is making assignments at the beginning of the shift. Which of the following tasks should the nurse delegate to the PN? a. obtain vital signs for a client who is 2 hr postprocedure following a cardiac catheterization b. administer a unit of packed red blood cells (RBCs) to a client who has cancer c. instruct a client who is scheduled for discharge in the performance of wound care d. develop a plan of care for a newly admitted client who has pneumonia

a. obtain vital signs for a client who is 2 hr postprocedure following a cardiac catheterization ATI Leadership and Management

A charge nurse is making assignments for an oncoming shift. Which of the following clients should the charge nurse assign to a LPN? a. A client who is to be discharged with a PICC line b. A client who is disoriented and awaiting transfer to a long term facility c. A client who is 16 hr post op following a total larryngectomy

b. A client who is disoriented and awaiting transfer to a long term facility

A nurse is working with an AP who appears to be under the influence of alcohol during the night shift. Which of the following is the priority action the nurse should take? a. Confront the AP regarding alcohol use and remove him from the client care b. Ask the nursing supervisor to obverse the AP and validate the nurse's suspicions c. Document observations made about the AP's behavior in a factual manner

b. Ask the nursing supervisor to observe the AP and validate the nurse's suspicions

A nurse is discussing with a newly licensed nurse about how to obtain informed consent from a client who is to undergo an epidural procedure. Which of the following ethical principles should the nurse include in the teaching? a. Benedicence b. Autonomy c. Paternalism

b. Autonomy

A nurse manager calls a meeting of the unit's staff members to discuss cost-containment issues. The nurse manager has asked for staff input regarding strategies that might help reduce costs. Which of the following types of leadership is the nurse manager using? a. Autocratic b. Democratic c. Laissez-faire d. Moral

b. Democratic

A nurse is delegating a task to an AP. The AP is to transfer a pt who has a below the knee amputation from a bed to a wheelchair. The AP has never transferred a pt with an amputation before. Which of the following actions should the nurse take? a. provide the AP with a manual on how to b. assist the AP after he has practiced the transfer c. transfer the client while the AP observes

b. assist the AP after he has practiced the transfer

A nurse is caring for a child who has sustained extensive head injuries. The provider has diagnosed brain death. Which of the following statements should the nurse use to begin a conversation about the option of organ and tissue donation with the child's parents? a. I want to talk to you how important it is for you to consider donating your child's organs for transplantation b. I want to give you some info about an option that you have regarding donating your child's organs to others who are in need.

b. I want to give you some info about an option that you have regarding donating your child's organs to others who are in need

A patient with an acute peptic ulcer and major blood loss requires an immediate transfusion with packed red blood cells. Which task is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Confirm the IV solution is 0.9% saline. b. Obtain the vital signs before the transfusion is initiated. c. Monitor the patient for shortness of breath and back pain. d. Double check the patient identity and verify the blood product.

b. Obtain the vital signs before the transfusion is initiated. MS ch 30

What is the most appropriate task for the RN to delegate to the NAP? a. silence the IV pump until the RN arrives b. notify the family of a pt who has died c. administer a soap spuds enema to a pt who has requested it for constipation d. reinforce teaching to a pt who has had an above the knee amputation

c. administer a soap spuds enema to a pt who has requested it for constipation Leadership and Management

Which intervention should the nurse delegate to the licensed practical nurse (LPN) when caring for a pt following an acute stroke? a. assess the pt's neurological status b. assess the pt's gag reflex before beginning feeding c. administer ordered antihypertensives and platelet inhibitors d. teach the pt's caregivers strategies to minimize unilateral neglect

c. administer ordered antihypertensives and platelet inhibitors MS workbook ch 57

An RN and a LPN are caring for a pt who has a small bowl obstruction and is NPO with a NG tube set to continuous suction. Which of the following tasks should the RN perform? a. obtain daily weight b. inspect the pt oral cavity for dryness hourly c. assess for bowel sounds every 2 hrs

c. assess for bowel sounds every 2 hrs

Using quality monitoring tools, a facility committee identifies that clients who have congestive heart failure have an average length of stay that is 5 days instead of the established standard of 3 days. Which of the following steps should the nurse implement next in the quality improvement process? a. educate staff members on shortening the length of stay for these patients b. collect data regarding length of stay for these patients c. determine which actions can be instituted to address this problem

c. determine which actions can be instituted to address this problem

A nurse is completing an incident report after administering an incorrect dose of med to a patient, even though the client experienced no ill effects from the error. Which of the following should the nurse recognize as the purpose for completing the incident report? a. Alerts facility administration of a possible litigation situation b. Tracks employee performance for possible disciplinary action c. Provides detailed report of the occurrence for the family d. Identifies situations that contribute to the occurrence of med erros

d. Identifies situations that contribute to the occurrence of med errors

A nurse is reviewing lab results for a client who is at 12 weeks gestation. Which of the following findings should the nurse report to the provider? a. Hgb 12 g/dL b. WBC 15,000/mm3 c. Fasting blood glucose 80 mg/dL d. Serum creatinine 0.4 mg/dL

d. Serum creatinine 0.4 mg/dL

A nurse is providing discharge teaching about home safety with an older adult client and his family. Which of the following statements should the nurse include in the teaching? a. you should set the water heater temp to 125 degrees F b. you should grasp the cord when unplugging it c. you should use a gas stove for cooking d. you should install a handrail on at least one side of the stairs

d. you should install a handrail on at least one side of the stairs

A nurse is caring for a client who is in the bathroom. The nurse hears a loud thud and, after opening the bathroom door, finds the client on the floor. What is priority action?

determine LOC

Right Task factors are:

the task is repetitive, requires little supervision & is relatively non-invasive