NCLEX: Management of Care, Interprofessional Collaboration, Delegating & Supervising W/ Rationales

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for the assistive personnel (AP)? 1. A client scheduled to receive parenteral nutrition 2. A client who requires assistance with ambulation every 4 hours 3. A client scheduled for discharge who needs teaching about medications 4. A client with bladder cancer who is scheduled for a cardiac catheterization

2. A client who requires assistance with ambulation every 4 hours Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for an AP would be to care for a client on bed rest who requires assistance with ambulation every 4 hours. The AP is trained in this procedure. The client receiving parenteral nutrition and the client scheduled for a cardiac catheterization require the assessment skills that a licensed nurse can perform. Teaching needs to be done by the licensed nurse. The AP does not have the education to teach a client about medications.

The nurse is delegating the morning hygienic care to the assistive personnel (AP). In reviewing the assigned tasks, the nurse would instruct the AP to use an electric razor for which client? 1. The client with severe pain related to osteoporosis 2. The client with hypokalemia related to diuretic therapy 3. The client with thrombocytopenia related to chemotherapy 4. The client with an elevated white blood cell count related to infection

3. The client with thrombocytopenia related to chemotherapy Rationale: The client with thrombocytopenia has a low platelet count. Using a straight razor increases the risk of abrasion and bleeding caused by ineffective clotting capability. The client with hypokalemia has a low potassium level. Shaving the client has no relationship to the client's potassium level. The client with severe pain is not affected by the different choices in shaving tools. Likewise, the client with an elevated white blood cell count will not be affected by the different choices in shaving tools.

A nurse is caring for a pediatric client diagnosed with intussusception who has undergone surgery. Which task(s) can the nurse delegate to the assistive personnel (AP) in the care of the child? Select all that apply. 1. Dressing changes 2. Vital signs every shift 3. Auscultating bowel sounds 4. Assessing whether sutures are intact 5. Providing assistance with bathing 6. Administering IV fluids per provider's order

2. Vital signs every shift 5. Providing assistance with bathing Rationale: Intussusception is the most common cause of intestinal obstruction in children and is a condition in which the proximal segment of the bowel slides into the distal segment. This telescoping action often blocks food or fluid from passing through. This condition can also cut off the blood supply to the part of the intestine that's affected. Assistive personnel are unlicensed but can take vital signs and assist with activities of daily living, such as bathing. The AP cannot do dressing changes, auscultate for bowel sounds, assess sutures, or administer IV fluids because these activities are not within the AP's scope of practice.

A client with diabetes mellitus is admitted to the hospital for eye surgery. Which task does the nurse plan to delegate to the assistive personnel (AP)? 1. Orient the client to the hospital surroundings. 2. Instruct the client on how to apply the eye drops. 3. Listen to the client express their frustration or loss. 4. Review hand-washing and hygiene practices with the client.

1. Orient the client to the hospital surroundings. Rationale: Orienting the client to the hospital room and surroundings is within the scope of the AP's responsibilities. Instructing on the use of eye drops, reviewing hand washing, and therapeutically listening to the client's emotions require formative evaluation to gauge client readiness. These activities are the responsibilities of the registered nurse. Teaching and assessments cannot be delegated to APs.

The charge nurse is planning the assignments for the day. Which factors would 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. The clients' needs and workers' needs and abilities

1. The acuity level of the clients 5. The clients' needs and workers' needs and abilities Rationale: There are guidelines that the nurse would use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the state's nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments.

The registered nurse (RN) has provided instructions to a licensed practical nurse (LPN) regarding administering enemas to a client scheduled for a barium enema. The RN has instructed the LPN to administer enemas until they are clear. The LPN tells the RN that three enemas were administered and that the returns are still not clear. What most appropriate instruction would be given to the LPN? 1. Administer one more enema. 2. Stop administering the enemas. 3. Continue to administer enemas until the solution is clear. 4. Wait for 1 hour and then continue administering the enemas.

2. Stop administering the enemas. Rationale: Client preparation for a barium enema may include the administration of enemas before the test. If administering enemas until clear is prescribed on the morning of the test, enemas would be administered no more than three times. The continuous administration of enemas may cause fluid and electrolyte disturbances and imbalances.

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the assistive personnel (AP)? Select all that apply. 1. The client receiving a heparin infusion 2. The client receiving a blood transfusion 3. The client receiving continuous oxygen at 2 L/min 4. The client recovering from Guillain-Barré syndrome 5. The client who just returned from surgery for a hip repair 6. The client on isolation for methicillin-resistant Staphylococcus aureus

3. The client receiving continuous oxygen at 2 L/min 4. The client recovering from Guillain-Barré syndrome 6. The client on isolation for methicillin-resistant Staphylococcus aureus Rationale: APs cannot be assigned to a client requiring care that is more than basic. APs do not have the education to safely care for clients requiring more than basic care. Assigning a AP to these clients presents an unsafe situation. The client receiving a heparin infusion requires licensed personnel to monitor progress and for possible adverse reactions. The client receiving a blood transfusion requires monitoring for possible adverse reactions; licensed personnel are necessary. Unlicensed personnel cannot be assigned to a client who needs immediate postoperative assessment. These clients need to be cared for by a registered nurse (RN).

The registered nurse is creating the plan for client assignments for the day. Which is the most appropriate assignment for the assistive personnel (AP)? 1.A client scheduled to receive a blood transfusion 2. A client with bladder cancer who will be receiving chemotherapy 3. A client newly diagnosed with diabetes mellitus scheduled for discharge 4. A client on bed rest who requires range-of-motion (ROM) exercises every 4 hours

4. A client on bed rest who requires range-of-motion (ROM) exercises every 4 hours Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the AP would be to care for the client on bed rest who requires ROM exercises. The AP is trained in this procedure. The client receiving chemotherapy and the client receiving a blood transfusion require assessment skills that only a licensed nurse can perform. The client with diabetes mellitus who is being discharged will require predischarge review of diabetic management instructions and coordination of necessary home care services.

The nurse employed in 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 nurse and three assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? 1. A client who requires a bed bath 2. An older client requiring frequent ambulation 3. A client who requires hourly measurement of vital signs 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 Rationale: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be assigned most appropriately to an AP. The licensed practical nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care.

A registered nurse (RN) who is working with a nursing student assigns the student to care for a client with a diagnosis of Cushing's syndrome. The RN asks the student questions about this disorder. Which statement made by the student indicates understanding of Cushing's syndrome? 1. "Cushing's syndrome is caused by excessive amounts of cortisol." 2. "Cushing's syndrome is caused by decreased amounts of aldosterone." 3. "Cushing's syndrome is caused by excessive amounts of antidiuretic hormone." 4. "Cushing's syndrome is caused by decreased amounts of parathyroid hormone."

1. "Cushing's syndrome is caused by excessive amounts of cortisol." Rationale: Cushing's syndrome is a condition caused by excessive amounts of cortisol. Options 2, 3, and 4 are inaccurate descriptions of this disorder.

The staff members working at the trauma center have characterized their nurse manager as task oriented and directive. Which leadership style does the nurse manager exhibit? 1. Autocratic 2. Situational 3. Democratic 4. Laissez-faire

1. Autocratic Rationale: The autocratic style of leadership is task oriented and directive. The situational leadership style uses a style that depends on the situation and events. The democratic style best empowers staff toward excellence because this type of leadership allows nurses to provide input and provides an opportunity to grow professionally. The laissez-faire style allows staff to work without assistance, direction, or supervision.

The registered nurse (RN) is planning her client assignments for the day. The RN has a licensed practical nurse and an assistive personnel (AP) on the team. Which task would the RN delegate to the AP? 1. Empty a client's urinary catheter bag. 2. Instruct a client on their new diabetic diet. 3. Teach a client how to check their blood glucose. 4. Evaluate a newly admitted client's home medications.

1. Empty a client's urinary catheter bag. Rationale: The nurse must delegate tasks according to the educational level of staff members. Unlicensed personnel such as an AP can perform tasks that are noninvasive, such as emptying a urinary catheter bag. Additionally, APs are not trained to teach or evaluate. Only an RN can teach, evaluate, and instruct.

The graduate nurse is interviewed by the manager of a unit and is told that the manager's leadership style is laissez-faire or one of letting the staff nurses make the decisions about the unit's operations. Which question by the graduate nurse indicates the best understanding of the laissez-faire leadership style? 1. "As the manager, do you maintain control and make all decisions?" 2. "As the manager, do you assume a passive, nondirective approach?" 3. "As the manager, do you facilitate decision making within the group?" 4. "As the manager, do you change style according to the needs of the group?"

2. "As the manager, do you assume a passive, nondirective approach?" Rationale: A laissez-faire leader assumes a passive, nondirective approach. Option 1 describes an autocratic leader; this type of leader would make the decisions. Option 3 describes a democratic leader. This type of leader is a "talk with the members" type of leader who gains input and facilitates decision making by the group. Option 4 describes a situational leader; this is seen when a manager indicates that in some situations, the manager decides, but in other situations, the staff nurses decide.

The nurse would instruct the assistive personnel (AP) to avoid the use of a straight razor for which client? 1. The postoperative client 2. The client taking warfarin 3. The client with an infection 4. The client taking acetaminophen

2. The client taking warfarin Rationale: Warfarin is an anticoagulant, which places the client at risk for bleeding. Use of a straight razor increases the risk of abrasion and bleeding because of the client's ineffective clotting capability. Postoperative status, infection, and taking acetaminophen are not affected by the choice of shaving tools.

When creating an assignment for a team consisting of a registered nurse (RN), a licensed practical nurse (LPN), and two assistive personnel (APs), which is the best client for the LPN? 1. Autocratic 2. Situational 3. Democratic 4. Laissez-faire

3. Democratic Rationale: Democratic styles empower staff toward excellence because this style of leadership allows nurses an opportunity to grow professionally. The autocratic style is task oriented and directive. Situational leadership uses a style that depends on the situation and events. Laissez-faire allows staff to work without assistance, direction, or supervision.

The nurse takes a newly admitted client's vital signs, completes an admission assessment history on the client, and assists the client to change into a hospital gown. By completing these tasks, the nurse is demonstrating which role of the nurse? 1. Manager 2. Educator 3. Advocate 4. Caregiver

4. Caregiver Rationale: The nurse is practicing basic nursing skills. Some of the tasks can be delegated, but the nurse chose to perform them, so the nurse is acting as a caregiver. A manager coordinates the care of a client, an educator teaches a client, and an advocate upholds a client's rights.

The nurse is giving a report to an assistive personnel (AP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the AP to check the skin integrity of the restrained hands how frequently? 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 30 minutes

4. Every 30 minutes Rationale: The nurse would instruct the AP to check safety devices and skin integrity every 30 minutes. The neurovascular and circulatory status of the extremity would also be checked every 30 minutes. In addition, the safety device needs to be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of safety devices would always be followed.

The nurse is rearranging the client assignments after several discharges and admissions occurred. Which tasks would be assigned to the assistive personnel (AP)? Select all that apply. 1. Cleaning a client's dentures 2. Ambulating a postoperative client 3. Taking 4:00 p.m. vital signs on clients 4. Giving medications left by the nurse for the client to take 5. Assisting a client with a urinary drainage catheter into a chair 6. Obtaining a catheterized urinalysis and taking it to the laboratory

1. Cleaning a client's dentures 2. Ambulating a postoperative client 3. Taking 4:00 p.m. vital signs on clients 5. Assisting a client with a urinary drainage catheter into a chair Rationale: Medication administration and invasive procedures, such as urinary catheterization for specimen collection, cannot be done by the AP; therefore, these options are incorrect. The remaining options identify activities that can be performed by the AP.

The nurse is giving report to an assistive personnel (AP) who will be caring for a client who has hand restraints (safety devices) applied. How frequently would the nurse instruct the AP to remove the restraints to allow for muscle activity? 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 6 hours

1. Every 2 hours Rationale: The nurse would instruct the AP to remove the safety device at least every 2 hours to permit muscle exercise and to promote circulation. Options 2, 3, and 4 are incorrect because they are too infrequent time checks. Agency guidelines regarding the use of safety devices would always be followed.

The newly appointed vice president for nursing operations has announced that the authority for decision making will be decentralized and distributed throughout the organization. Which term describing this organizational chart would the vice president employ while talking with the employees? 1. Flat 2. Vertical 3. Circular 4. Horizontal

1. Flat Rationale: Organizational charts are drawings that show how the parts of an organization are linked. In "flat" organizations, authority and responsibility are delegated to the lowest operational level possible. Option 2 is incorrect because a vertical chart indicates a formal line of authority and communications. Traditionally, vertical charts indicate decision making at the upper levels of management. Option 3 indicates a concentric or circular chart, with the chief executive in the center and successive layers of authority. Option 4 refers to a horizontal, or left-to-right, chart that depicts the chief executive at the left, with lower layers of the authority to the right.

A nursing instructor asks the nursing student to describe the definition of a critical path. Which statement, if made by the student, indicates a need for further teaching regarding critical paths? 1. "They are developed based on appropriate standards of care." 2. "They are nursing care plans and use the steps of the nursing process." 3. "They are developed through the collaborative efforts of members of the health care team." 4. "They provide an effective way to monitor care and to reduce or control the length of hospital stay for the client."

2. "They are nursing care plans and use the steps of the nursing process." Rationale: Critical paths are not specifically nursing care plans; however, they can take the place of a nursing care plan and actually map out the desired clinical progress of a client during acute care admission. All other options appropriately describe the use of a critical path.

The nurse is planning the client assignments for the shift. Which client would the nurse assign to the assistive personnel (AP)? 1. A client requiring dressing changes 2. A client requiring frequent temperature measurements 3. A client on a bowel management program requiring rectal suppositories and a daily enema 4. A client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures

2. A client requiring frequent temperature measurements Rationale: Assignment of tasks to the AP needs to be made based on job description, level of clinical competence, and state law. Options 1, 3, and 4 involve care that requires the skill of a licensed nurse. The client described in the correct option has needs that can be met by an AP.

The nurse manager has involved all staff members in the planning and development of goals and decision making. Which leadership style has the unit manager exercised? 1. Autocratic 2. Democratic 3. Situational 4. Laissez-faire

2. Democratic Rationale: Democratic leadership is defined as participative, with a focus on the belief that all members of the group have input into the decision-making process. This leader acts as a resource and facilitator. Autocratic leadership dominates the group, with maintenance of strong control over the group. Situational leadership is based on the current events of the day. Laissez-faire leaders assume a passive approach, with the decision making left to the group.

The nurse is caring for a client with acute glomerulonephritis. The nurse instructs the assistive personnel (AP) to implement which action when caring for the client? 1. Ambulate the client frequently. 2. Encourage a diet that is high in protein. 3. Remove the water pitcher from the bedside. 4. Monitor the client's temperature every 2 hours.

3. Remove the water pitcher from the bedside. Rationale: The client with acute glomerulonephritis commonly experiences an excess of fluid volume and fatigue. Interventions include fluid restriction and monitoring weight, intake, and output. The diet is high in calories but low in protein. The client is placed on bed rest, or at least encouraged to rest, because there is a direct correlation between proteinuria and hematuria and increased activity levels. It is unnecessary to monitor the temperature as frequently as every 2 hours.

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? 1. Each staff member is assigned a specific task for a group of clients. 2. A staff member is assigned to determine the client's needs at home and begin discharge planning. 3. A single registered nurse (RN) is responsible for providing care to a group of six clients with the aid of an assistive personnel (AP). 4. An RN leads two licensed practical nurses (LPNs) and three APs in providing care to a group of 12 clients.

4. An RN leads two licensed practical nurses (LPNs) and three APs in providing care to a group of 12 clients. Rationale: In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice).

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the assistive personnel (AP)? Select all that apply. 1. A client needing a bed bath 2. A client needing to ambulate 3. A client needing packed red blood cells 4. A client requiring assistance with feeding 5. A client needing to have vital signs checked 6. A client needing to use the bedside commode

1. A client needing a bed bath 2. A client needing to ambulate 4. A client requiring assistance with feeding 5. A client needing to have vital signs checked 6. A client needing to use the bedside commode Rationale: APs can perform tasks that are noninvasive. Therefore, options 1, 2, 4, 5, and 6 are tasks that the AP can perform. The client in option 3 must be cared for by the registered nurse.

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the assistive personnel (AP)? Select all that apply. 1. A confused older client who requires feeding 2. A client who requires turning every 2 hours 3. A client admitted with dehydration who is on strict intake and output 4. A client on 3 L of oxygen by nasal cannula and a pulse oximetry reading of 89% 5. A client who experienced a 10-beat run of ventricular tachycardia and hypotension on the previous shift 6. A client 4 days postoperative after exploratory laparotomy who requires ambulation in the hallway 4 times a day

1. A confused older client who requires feeding 2. A client who requires turning every 2 hours 3. A client admitted with dehydration who is on strict intake and output 6. A client 4 days postoperative after exploratory laparotomy who requires ambulation in the hallway 4 times a day Rationale: Activities such as turning, ambulation, maintenance of intake and output, and feeding can be delegated to the AP. Therefore, clients 1, 2, 3, and 6 can be assigned to the AP. The clients in options 4 and 5 are unstable or have demonstrated recent instability and would be assigned to the registered nurse for comprehensive assessment.

The home health nurse develops a plan of care for the client. Which actions would the nurse plan as a case manager of the client's care? 1. Organize, manage, and balance health care services needed for the client. 2. Report daily to all members of the client's health care team to advise them of the plans. 3. Plan weekly meetings with all persons involved in the care of this client to assess status. 4. Conduct daily teaching sessions for the client and significant others about the case management process.

1. Organize, manage, and balance health care services needed for the client. Rationale: The role of the case manager is to organize, manage, and balance health care services needed for the client. Although options 2, 3, and 4 may be aspects of the role of the case manager, the correct option identifies the overall role.

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

3. A client who requires urine specimen collections Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the AP would be to care for the client who requires urine specimen collections. The AP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by APs because these are invasive procedures. The client with difficulty swallowing food and fluids is at risk for aspiration.

A registered nurse is delegating activities to the nursing staff. Which activities are most appropriate for the assistive personnel (AP)? Select all that apply. 1. Collecting a urine specimen from a client 2. Obtaining frequent oral temperatures on a client 3. Accompanying a client being discharged to their transportation to home 4. Assisting a postcardiac catheterization client who needs to lie flat to eat lunch 5. Monitoring the amounts of fluid remaining in intravenous (IV) solution bags for a client receiving IV fluids

1. Collecting a urine specimen from a client 2. Obtaining frequent oral temperatures on a client 3. Accompanying a client being discharged to their transportation to home Rationale: Work that is delegated to others must be done consistent with the individual's level of expertise and licensure or lack of licensure. Based on the options provided, the most appropriate activities for an AP are noted in options 1, 2, and 3. These options do not include situations to indicate that these activities carry any risk. Because the client in option 4 needs to eat lying flat, the client is at risk for aspiration. Care related to IV therapy, as in option 5, needs to be done by a licensed nurse.

The registered nurse (RN) is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has one RN, one licensed practical nurse, and two assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? 1. The client who requires a 24-hour urine collection 2. The client with an abdominal wound requiring frequent wound irrigations. 3. The older client requiring assistance with a bed bath and frequent ambulation. 4. The client on a mechanical ventilator requiring frequent assessment and suctioning.

2. The client with an abdominal wound requiring frequent wound irrigations. Rationale: When delegating nursing assignments, the nurse must consider the skills and educational level of the nursing staff. The licensed practical nurse is skilled in wound irrigation and dressing changes, so this client would be assigned to this staff member. Collecting 24-hour urine and helping with a bed bath and frequent ambulation can most appropriately be assigned to the APs. The client on the mechanical ventilator requiring frequent assessment and suctioning would most appropriately be cared for by the RN.

The nurse manager is planning the clinical assignments for the day. Which staff members would not be assigned to care for a client with herpes zoster? Select all that apply. 1. The nurse who never had roseola 2. The nurse who never had mumps 3. The nurse who never had chicken pox 4. The nurse who never had German measles 5. The nurse who never received the varicella-zoster vaccine

3. The nurse who never had chicken pox 5. The nurse who never received the varicella-zoster vaccine Rationale: The nurses who have not had chicken pox or did not receive the varicella-zoster vaccine are susceptible to the herpes zoster virus and would not be assigned to care for the client with herpes zoster. Nurses who have not contracted roseola, mumps, or rubella are not necessarily susceptible to herpes zoster. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the causative virus of chicken pox. Individuals who have not been exposed to the varicella-zoster virus or who did not receive the varicella-zoster vaccine are susceptible to chicken pox. Health care workers who are unsure of their immune status would have varicella titers done before exposure to a person with herpes zoster.

The nurse is preparing the client assignment. Which client would the nurse plan to assign to a licensed practical nurse (LPN)? 1. A client who requires teaching about an insulin pump 2. Completing an admission assessment on a newly admitted client 3. Administration of a new oral medication to a client with Alzheimer's disease 4. An assessment of a client whose pulse oximetry reading is 85% and who is having difficulty breathing

3. Administration of a new oral medication to a client with Alzheimer's disease Rationale: Oral medication administration is within the scope of practice for an LPN. Teaching is the responsibility of the registered nurse (RN). Assessments are also done by the RN. The LPN's scope of practice is restricted to data collection.

The nurse is planning client assignments for the day. Which clients can be safely assigned to assistive personnel (APs)? Select all that apply. 1. Client who is receiving chemotherapy and is in isolation 2. Client with anemia who is receiving a second unit of blood and needs assessment of vital signs 3. Client newly diagnosed with hyperthyroidism who is in need of teaching regarding medication therapy 4. Client who is 72 hours postoperative recovering from a total knee replacement and needs assistance with bathing and dressing 5. Client who is 48 hours postoperative recovering from an open reduction and fixation of the right forearm and needs assistance with feeding 6. Client who is newly admitted with shortness of breath, circumoral cyanosis, and a respiratory rate of 30 breaths per minute who requires an admission assessment

4. Client who is 72 hours postoperative recovering from a total knee replacement and needs assistance with bathing and dressing 5. Client who is 48 hours postoperative recovering from an open reduction and fixation of the right forearm and needs assistance with feeding Rationale: The scope of practice of APs includes the measurement of vital signs and assistance with feeding, bathing, and dressing. Clients who need assessment, who are receiving chemotherapy or are receiving blood, or who require education need the more advanced skills of a licensed nurse.

The nurse is developing client care assignments for a group of assistive personnel (APs). What is the nurse's first step in planning and assigning clients? 1. Determine what skills can be delegated. 2. Determine the years of experience of each AP. 3. Determine how much supervision is required for each client assigned. 4. Determine how many clients the agency allows to be delegated to each AP.

1. Determine what skills can be delegated. Rationale: Knowing what skills can be delegated is essential when nurses assign client care to other health care personnel. Nurses must be familiar with their state's nurse practice act, institutional policies and procedures, and the institution's job description for APs. Information from these sources is necessary to define the level of competency of APs. Determining how many clients to delegate is not the first step; in fact, most agencies do not state a specific number of clients that may be assigned. Determining years of experience is also not a first step, although an AP's experience could affect the type of client assigned. How much supervision will be required is also important, but, again, not the first step the nurse takes when delegating client assignments to the APs.

The charge nurse is planning the assignment for the day. Which factors would the nurse remain mindful of when delegating tasks? 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 Rationale: There are guidelines that the nurse would use when delegating tasks. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience (as in clustering of client rooms), and anticipated changes in unit census are not specific guidelines to use when delegating tasks, but may be considered when making assignments.

The registered nurse (RN) is planning client assignments and cannot take a client assignment today. Two assistive personnel (AP) and a licensed practical nurse (LPN) also are assigned to the unit. Which client would the RN most appropriately assign to the LPN? 1. A client requiring frequent ambulation 2. A client scheduled for a cardiac catheterization 3. A client requiring range-of-motion (ROM) exercises 4. A client with a 24-hour urine collection who is on strict bed rest

2. A client scheduled for a cardiac catheterization Rationale: The RN is legally responsible for client assignments and must assign tasks according to the guidelines of the Nurse Practice Act and the job description of the employing agency. A client scheduled for a cardiac catheterization requires physiological needs and frequent nursing assessments; this is the most appropriate assignment for the LPN. The RN can work with the LPN and supervise care. The AP has been trained to care for a client on bed rest and on urine collection, to provide assistance with ambulation, and to perform ROM exercises. The RN would provide instructions to the AP regarding the tasks, but the tasks required for these clients are within the role description of an AP.

The nurse is planning the client assignments and has a licensed practical nurse (LPN) and an assistive personnel (AP) on the nursing team. Which client would the nurse most appropriately assign to the LPN? 1. A client with stable heart failure who has early-stage Alzheimer's disease 2. A client who is scheduled for an electrocardiogram and a chest x-ray examination 3. A client who was treated for dehydration, is weak, and needs assistance with bathing 4. A client with emphysema who is receiving oxygen at 2 L/min by nasal cannula and becomes dyspneic on exertion

2. A client who is scheduled for an electrocardiogram and a chest x-ray examination Rationale: The nurse would most appropriately assign the client with emphysema to the LPN. This client has an airway problem and has the highest priority needs among the clients presented in the options. The clients described in options 1, 2, and 3 can appropriately be cared for by the AP.

The registered nurse (RN) directs the licensed practical nurse (LPN) to assist with the care of a client who has a sacral pressure injury. Which is the most appropriate activity for the RN to delegate to the LPN? 1. Place the client in a side-lying position. 2. Initiate wound care protocol for standardized ulcer care. 3. Meet with the wound specialist to identify measures to improve healing. 4. Determine which treatments would best meet the healing needs of the client.

2. Initiate wound care protocol for standardized ulcer care. Rationale: The best task for the LPN is to place the client in the side-lying position. Proper positioning requires nursing skills and is within the LPN's abilities and scope of practice. Initiating a wound care protocol, meeting with the wound specialist to identify measures to improve healing, and determining which treatments would best meet the healing needs of the client are outside the LPN's scope of practice, even though the LPN may assist the RN in determining the plan of care. These activities are the RN's responsibilities.

The nurse manager is discussing with the staff the facility's protocol in the event of a tornado. Which instructions would the nurse manager include in the discussion? Select all that apply. 1. Open doors to client rooms. 2. Move beds away from windows. 3. Close window shades and curtains. 4. Place blankets over clients who are confined to bed. 5. Relocate ambulatory clients from the hallways back into their rooms.

2. Move beds away from windows. 3. Close window shades and curtains. 4. Place blankets over clients who are confined to bed. Rationale: In this weather event, the appropriate nursing actions focus on protecting clients from flying debris or glass. The nurse would close doors to each client's room and move beds away from windows, and close window shades and curtains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets need to be placed over clients confined to bed. Ambulatory clients need to be moved into the hallways from their rooms, away from windows.

When creating an assignment for a team consisting of a registered nurse (RN), a licensed practical nurse (LPN), and two assistive personnel (APs), which is the best client for the LPN? 1. A client requiring frequent temperature checks 2. A client requiring assistance with ambulation every 4 hours 3. A client on a mechanical ventilator requiring frequent assessment and suctioning. 4. A client with a spinal cord injury requiring urinary catheterization every 6 hours.

4. A client with a spinal cord injury requiring urinary catheterization every 6 hours. Rationale: When creating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Frequent temperature checks and ambulation can most appropriately be provided by the APs, considering the clients identified in each option. The client on the mechanical ventilator requiring frequent assessment and suctioning would most appropriately be cared for by the RN. The LPN is skilled in urinary catheterization, so the client in option 4 would be assigned to this staff member.

The nurse is responsible for the care of a client with schizophrenia who has begun to experience hallucinations more frequently. Which activity in the care of the client can be most appropriately delegated to an assistive personnel (AP)? 1. Determining whether the client has consistently been medication compliant 2. Providing distraction for the client by engaging the client in a board game 3. Discussing the frequency and duration of the hallucinations with the client 4. Assisting the client in identifying any new stressors he or she may be experiencing

2. Providing distraction for the client by engaging the client in a board game Rationale: Although all of the options represent appropriate interventions, APs are permitted only to engage the client in a distraction such as a board game, and so it is an intervention that the nurse may delegate after sufficiently instructing the AP. The other options—assessing medication compliance, discussing the characteristics of the hallucinations, and identifying stressors—are nursing responsibilities and may not be delegated to an AP.

Which tasks would the registered nurse (RN) delegate to the licensed practical nurse (LPN)? Select all that apply. 1. Assessment 2. Urinary catheterization 3. Endotracheal suctioning 4. Intramuscular medication administration 5. Subcutaneous medication administration 6. Intravenous push medication administration

2. Urinary catheterization 3. Endotracheal suctioning 4. Intramuscular medication administration 5. Subcutaneous medication administration Rationale: In general, an LPN can perform the tasks that an assistive personnel can perform (skin care, range-of-motion exercises, grooming, ambulation, hygiene measures) as well as dressing changes, endotracheal suctioning, urinary catheterization, and medication administration (oral, subcutaneous, intramuscular, some piggyback medications). Assessment and administration of intravenous medications are responsibilities of the RN and outside of the scope of practice of the LPN.

A case manager is reviewing the records of the clients in the nursing unit. Which occurrence, if noted in a client's record, would the nurse identify as a positive variance? 1. A client is performing colostomy irrigations. 2. The client with a leg ulcer is demonstrating signs of wound healing. 3. A postoperative client is discharged home 1 day earlier than expected. 4. The client with diabetes mellitus is administering insulin injections appropriately.

3. A postoperative client is discharged home 1 day earlier than expected. Rationale: Variances are actual deviations or detours from the critical path. Variances are positive or negative, avoidable or unavoidable, and may be caused by a variety of factors. A positive variance occurs when the client achieves maximum benefits and is discharged earlier than anticipated on his or her critical path. The correct option is the only one that identifies a positive variance. Options 1, 2, and 4 demonstrate progression on a critical path, but they are not specifically associated with the definition of a positive variance.

The nurse manager meets with the staff nurses and announces that management has developed a new policy and procedure that is significantly different from old practices. Which statement by the nurse manager reflects the manager's use of legitimate power? 1. "The health care system services a client population that presents particular challenges. The changes made will enhance client safety and reduce errors." 2. "If you don't follow the new policy and procedure, I'll have no choice but to give you a notice about poor performance, which could lead to termination of your employment." 3. "Every manager has the responsibility to see that these new policies and procedures are followed 100% of the time. Please join me in this organization's effort to continue to improve quality care." 4. "You're just going to have to trust me on this one. I was a member of the committee that wrote the policy and procedure, and there are good reasons why the specific nursing actions need to be done this new way."

3. "Every manager has the responsibility to see that these new policies and procedures are followed 100% of the time. Please join me in this organization's effort to continue to improve quality care." Rationale: Option 3 describes legitimate power. Legitimate power is based on a person's position within an organization or society. The organizational leadership has mandated performance outcomes, and management has the responsibility to see that the mandate is met. Option 1 demonstrates informational power. The manager is using data to drive compliance with the mandate. Option 2 reflects an example of coercive power. Coercive power is a "do this or else" type of approach. Option 4 reflects expert power. The manager is asking the staff nurses to comply with the mandate because the manager possesses expert knowledge and skill levels. In addition to coercive, informational, expert, and legitimate power, the manager has referent, reward, and personal power.

The nurse is preparing to perform a general survey of a client who was admitted to the hospital a few hours ago. Which components of the general survey may be delegated to the assistive personnel (AP)? Select all that apply. 1. Inspecting skin surfaces 2. Observing the client's behavior 3. Measuring the client's height and weight 4. Assessing the client's general appearance 5. Monitoring oral intake and urinary output

3. Measuring the client's height and weight 5. Monitoring oral intake and urinary output Rationale: The general survey is a review of the client's main health problems and includes assessment of vital signs, height and weight, general behavior, and appearance. The nurse can delegate some aspects, such as measuring height and weight and monitoring intake and output, to APs, but the nurse is responsible for performing the general survey, including assessment of general appearance, behavior, and skin.

The nurse educator presents an in-service training session on case management to nurses on the clinical unit. During the presentation the nurse educator clarifies that what is a characteristic of case management? 1. Requires that one nurse take care of one client. 2.Promotes appropriate use of hospital personnel 3. Requires a case manager who plans the care for all clients 4.Uses a team approach, but one nurse supervises all other employees.

3. Requires a case manager who plans the care for all clients Rationale: Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources; its aim is to maximize hospital revenues while providing for optimal outcomes of care. Case management manages client care by managing the client care environment. Options 1, 3, and 4 are not characteristics of case management.

A registered nurse (RN) is observing a licensed practical nurse (LPN) preparing a client for treatment with a continuous passive motion (CPM) machine. Which action by the LPN requires follow-up by the RN? 1. The LPN keeps the client's knee at the hinged joint of the machine. 2. The LPN assesses the client for pressure areas at the knee and the groin. 3. The LPN places the client's knee in a slightly externally rotated position. 4.The LPN checks the degree of extension and flexion and the speed of the CPM machine according to the primary health care provider's (PHCP's) prescriptions.

3. The LPN places the client's knee in a slightly externally rotated position. Rationale: In the use of a CPM machine, the leg needs to be kept in a neutral position and not rotated either internally or externally. The knee needs to be positioned at the hinge joint of the machine. The nurse would monitor for pressure areas at the knee and the groin and would follow the PHCP's prescriptions and institutional protocol regarding extension and flexion and the speed of the CPM machine.

The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply. 1. The nurse who never had roseola 2. The nurse who never had mumps 3. The nurse who never had chicken pox 4. The nurse who never had German measles 5. The nurse who never received the varicella-zoster vaccine

3. The nurse who never had chicken pox 5. The nurse who never received the varicella-zoster vaccine Rationale: The nurses who have not had chicken pox or did not receive the varicella-zoster vaccine are susceptible to the herpes zoster virus and should not be assigned to care for the client with herpes zoster. Nurses who have not contracted roseola, mumps, or rubella are not necessarily susceptible to herpes zoster. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the causative virus of chicken pox. Individuals who have not been exposed to the varicella-zoster virus or who did not receive the varicella-zoster vaccine are susceptible to chicken pox. Health care workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster.