Nurs 4 - Mod 1 - Management of care EAQ's

In addition to quality, patient-centered care is interrelated with which part of nursing? 1 Safety 2 Compassion 3 Nursing process 4 Evaluation of outcomes

1 - Safety Patient-centered care is interrelated with quality and safety. Compassion is a nursing quality. The nursing process is a problem-solving approach to the identification and treatment of patient problems. Evaluation of outcomes is part of the nursing process.

The nurse is caring for a patient with lung cancer. The nurse is legally able to delegate which of the following tasks to unlicensed assistive personnel (UAP)? 1 Taking vital signs 2 Suctioning the upper airway 3 Administrating blood products 4 Changing a central line dressing

1 - Taking vital signs Unlicensed assistive personnel are not able to perform skills that require ongoing assessment and evaluation. Nursing interventions that require independent nursing knowledge, skill, or judgment are the nurse's responsibility and cannot be delegated. Vital signs can be taken by unlicensed assistive personnel and reported to the registered nurse. Administration of blood products, central line dressing changes, and suctioning of the upper airway are tasks that the registered nurse must perform.

A nurse reviewing charts is participating in what part of the system of quality improvement? 1 Aim 2 Goals 3 Measures 4 Data collection plan

4 - Data collection plan A nurse reviewing charts is participating in the data collection plan part of the quality improvement system. Measures refer to the assessment of how well the healthcare team performed. Aim is a measurable description of the desired improvement. Goals are the proficiencies that need to be met.

4 - Patient D UAPs can take and report patient vital signs before and after pain administration. RNs must complete patient teaching and education as in Patient A's case. RNs and LPNs mist assess Patient B's pain; this is out of the UAP's scope. An RN must evaluate the patient's response to pain medications; this task cannot be delegated to the UAP.

4. A patient diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply. a. Offer laxatives, if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict the intake of processed foods.

In the event of a mass casualty, prioritized medical care is provided based on the triage of victims using colored tags. Which patient receives immediate intervention? 1 A patient with a red tag 2 A patient with a blue tag 3 A patient with a green tag 4 A patient with a yellow tag

1 - A patient with a red tag When a mass casualty incident occurs, the victims are triaged according to color-coded tags. These colored tags are used to designate both the seriousness of the injury and the likelihood of a patient's survival. Red indicates a life-threatening injury, such as shock that requires immediate intervention. Blue indicates those who are expected to die due to a massive head trauma. Green is for minor injuries like sprains, and yellow is for urgent, but not life-threatening injuries like open fractures. In general, two-thirds of patients are tagged green or yellow, and the remaining are tagged red, blue, or black.

A patient is receiving allergy skin testing and has itching and swelling at the injection site. What intervention should the nurse prioritize? 1 Administer epinephrine. 2 Assess for systemic rash. 3 Establish intravenous (IV) access. 4 Apply a topical antihistamine to the injection site.

1 - Administer epinephrine. The nurse should administer epinephrine in response to an allergic reaction, which is indicated by the itching and swelling. A topical antihistamine will not be as effective. The assessment of a systemic rash can wait until the patient has received epinephrine to prevent further allergic response. IV access may be necessary, but only if the epinephrine is ineffective.

When caring for a critically ill patient who is on a ventilator, what roles can the registered nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1 Measuring urine output of the patient 2 Monitoring ventilator settings and alarms 3 Monitoring oxygenation level during weaning 4 Performing bedside glucose testing, if needed 5 Administering routinely scheduled medications

1 - Measuring urine output of the patient 4 - Performing bedside glucose testing, if needed The registered nurse (RN) may delegate the measurement of urine output and the performance of bedside glucose testing to the unlicensed assistive personnel (UAP) if needed. The RNs themselves should monitor a patient's oxygenation levels as well as ventilator setting and alarms. The RN may delegate the administration of routinely scheduled medication to the licensed practical/vocational nurse (LPN/LVN) but not to the UAP.

The nurse is delegating responsibilities of patient care to a licensed practical nurse (LPN/licensed vocational nurse [LVN]). Which nursing activities are most appropriate to delegate to the LPN/LVN? Select all that apply. 1 Administration of oral medications 2 Assisting a stable patient with ambulation 3 Assessment of a newly admitted patient 4 Reassessing a patient with a blood pressure of 190/104 5 Dressing change for a patient with an abdominal wound

1 - Administration of oral medications 5 - Dressing change for a patient with an abdominal wound The administration of oral medications and a dressing change for a patient with an abdominal wound are the most appropriate skills to delegate to the LPN, because these are within the scope and standards of practice as defined by the state nursing practice act. The registered nurse (RN) can delegate these skills to the LPN. Nursing interventions that require independent nursing knowledge, skill, or judgment, such as assessment, patient teaching, and evaluation of care cannot be delegated. Assisting a stable patient with ambulation can be delegated to unlicensed assistive personnel (UAP). UAP are qualified to ambulate a stable patient. The assessment of a newly admitted patient is incorrect because the nursing interventions that require independent nursing knowledge, skill, or judgment, such as assessment, are the responsibility of the RN. The RN is skilled in assessments and should do all assessments. Reassessing a patient with a blood pressure of 190/104 is incorrect because the patient is not stable and requires reassessment. The RN should recheck and reassess the patient for validity of information and changes in status. The RN is skilled in assessments and in providing care to those patients who have unpredictable outcomes.

The registered nurse on a medical inpatient unit reviews the patient assignments. The nurse determines that it is appropriate to delegate which activities to unlicensed assistive personnel (UAP)? Select all that apply. 1 Check for postural changes in blood pressure (BP). 2 Make appropriate referrals to other health care professionals. 3 Teach patients about lifestyle management and medication use. 4 Report high or low blood pressure (BP) readings to the registered nurse. 5 Assess patients for hypertension risk factors and develop risk modification plans.

1 - Check for postural changes in blood pressure (BP). 4 - Report high or low blood pressure (BP) readings to the registered nurse. Reporting high or low BP readings and checking for postural changes in BP are repetitive activities and do not require nursing judgment. Therefore these activities can be delegated to unlicensed assistive personnel. Making appropriate referrals requires understanding of the collaborative care and judgment regarding the requirement of the referrals; this activity cannot be delegated and is the role of a registered nurse. Patient education about lifestyle management and medication use requires sound knowledge; therefore, this activity should be performed by the nurse. Assessment and development of risk modification plans requires assessment and planning skills; this activity should not be delegated and should be performed by the nurse.

The nurse is caring for a patient in the burn unit who has just undergone debridement of burn wounds. Which tasks are most appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Select all that apply. 1 Check the patient's vital signs. 2 Provide oral care before a meal. 3 Evaluate the patient's level of consciousness. 4 Teach the patient appropriate range of motion exercises. 5 Monitor the site of the patient's intravenous (IV) catheter.

1 - Check the patient's vital signs. 2 - Provide oral care before a meal. Specific activities that may be delegated to unlicensed assistive personnel (UAP) include routine vital signs on stable patients, feeding or assisting patients at mealtime, ambulating stable patients, and helping patients with bathing and hygiene. Nursing interventions that require independent nursing knowledge, skill, or judgment, such as assessment and evaluation of care, cannot be delegated.

When caring for a patient with sepsis and a suspected infection, which is the priority nursing intervention? 1 Initiate broad spectrum antibiotics. 2 Obtain blood cultures after antibiotic initiation. 3 Provide pain medication to increase patient comfort. 4 Hold antibiotic therapy until the organism is identified

1 - Initiate broad spectrum antibiotics. Once an infection is suspected, the nursing priority is to begin broad spectrum antibiotics therapy. Adjustments to antibiotic therapy, if needed, are based on culture results, but antibiotic therapy should not be delayed in patients with sepsis. Pain medication may be necessary but is not a nursing priority for treating infection. Blood cultures should be drawn before antibiotic therapy.

The nurse is planning care for a group of patients on a stroke unit. What tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply. 1 Measuring and recording oral intake and urine/bowel output 2 Screening patients for tissue plasminogen activator therapy 3 Assessing neurologic status using the Glasgow Coma Scale 4 Providing oral and lip care at least every 2 hours and as needed 5 Placing equipment needed for seizure precautions in the patient's room 6 Assisting with positioning the patient and turning the patient at least every two hours

1 - Measuring and recording oral intake and urine/bowel output 4 - Providing oral and lip care at least every 2 hours and as needed 5 - Placing equipment needed for seizure precautions in the patient's room 6 - Assisting with positioning the patient and turning the patient at least every two hours A registered nurse can delegate unlicensed assistive personnel to place equipment needed for seizure precautions in the patient's room, to assist with positioning the patient and turning the patient at least every two hours, to provide oral and lip care at least every 2 hours and as needed, and to measure and record oral intake and urine/bowel output. Only a registered nurse can screen patients for tissue plasminogen activator therapy and assess neurologic status using the Glasgow Coma Scale.

The nurse is developing a plan of care for a patient with an acute ischemic stroke in the first 48 hours after admission. What activity can the nurse delegate to the unlicensed assistive personnel (UAP)? 1 Measuring the urine output 2 Assessing the respiratory status 3 Assessing the swallowing ability 4 Monitoring the cardiovascular status

1 - Measuring the urine output Measuring the urine output is within the scope of practice of unlicensed assistive personnel (UAP). However, it is not within the UAP's scope of practice to assess the patient. Assessment of respiratory status and swallowing ability and monitoring cardiovascular status are only performed by the registered nurse.

What does the Health Insurance Portability and Accountability Act (HIPAA) consider to be private health information? Select all that apply. 1 Patient's name 2 Patient's picture 3 Treatment provided to a patient 4 Patent's future mental/physical health 5 Health information in education records 6 Health information in employment records

1 - Patient's name 2 - Patient's picture 3 - Treatment provided to a patient 4 - Patent's future mental/physical health A patient's private health information includes the patient's name, future mental/physical health, treatment provided, and the patient's picture. Health information in employment and education records is not considered protected health information under HIPAA.

Which tasks, if delegated by the registered nurse (RN), are beyond the subordinate's scope of practice? Select all that apply. 1 RN to LPN: administering intravenous phenytoin to a patient with epilepsy 2 RN to UAP: obtaining and recording vital signs on a district of patients in the hospital 3 RN to LPN: administering oral medication to a patient admitted with hypertension 4 RN to licensed practical nurse (LPN): initiating a blood transfusion to an elderly patient with chronic anemia 5 RN to unlicensed assistive personnel (UAP): reinforcing a draining abdominal dressing following a surgical procedure

1 - RN to LPN: administering intravenous phenytoin to a patient with epilepsy 4 - RN to licensed practical nurse (LPN): initiating a blood transfusion to an elderly patient with chronic anemia 5 - RN to unlicensed assistive personnel (UAP): reinforcing a draining abdominal dressing following a surgical procedure It is not within the LPN's scope of practice to initiate blood transfusion. The LPN may obtain vital signs at the request of the nurse, but he or she cannot assess the patient's toleration of blood products. The UAP should not be directed to reinforce a draining wound, as it is the nurse's responsibility to assess the outcome. The LPN is only permitted to initiate intravenous catheters, administer intravenous piggyback antibiotics, and maintain fluid administration. The LPN is not permitted to administer intravenous push drugs. The UAP is permitted to obtain and record vital signs on a district of patients. It is within the LPN's scope of practice to administer oral medications to a stable patient with hypertension.

The nurse has delegated to the patient care technician the task of passing medication to a patient. The nurse has been called away to answer a phone call from a primary health care provider. Which of the rights of delegation have been used incorrectly in this situation? Select all that apply. 1 Right task 2 Right person 3 Right patient 4 Right circumstances 5 Right supervision and evaluation 6 Right directions and communication

1 - Right task 2 - Right person 4 - Right circumstances 5 - Right supervision and evaluation 6 - Right directions and communication Professional nurses delegate nursing care and supervise others who are qualified to deliver care. It is not appropriate to delegate activities that are outside of the scope of practice for the role. Unlicensed personnel are not permitted to pass medications. The five rights of delegation are the right task, under the right circumstance, to the right person, with the right directions and communication, under the right supervision and evaluation. In this situation, the nurse did not follow any of the five rights. In this case, the patient is correct, though this is not one of the five rights of delegation.

When providing patient-centered care, what is most appropriate for the nurse to consider? 1 The patient's religion 2 The family's requests 3 The nurse's personal feelings 4 The patient's beliefs and values

4 - The patient's beliefs and values The nurse provides patient-centered care with sensitivity and respect, taking into consideration the patient's beliefs and values. The patient's religion may contribute to the patient's beliefs and values, but that is only one area for the nurse to consider, and a patient may not identify with any religion. The family's requests should be acknowledged, but ultimately the nurse should respect the patient's preferences. The nurse's feelings should not contribute to providing patient-centered care.

Which is most likely to result in negligence and abuse of a patient? 1 Cultural beliefs 2 Caregiver burnout 3 Environmental conditions 4 Family disagreements regarding care

2 - Caregiver burnout The stress associated with caregiving can lead to burnout, resulting in negligence and abuse of the patient by the caregiver. Cultural beliefs and environment conditions can be positive and supportive to promote optimal caregiving. Family disagreements regarding care are a cause of conflict between family members, not usually of abuse.

It is appropriate for the registered nurse (RN) to delegate which intervention to a licensed practical nurse (LPN) when providing care to a patient with venous thromboembolism? 1 Monitoring for adverse effects of anticoagulant use 2 Administering prescribed subcutaneous anticoagulants 3 Providing instructions about the use of pressure to stop bleeding 4 Teaching about the use of compression stockings during a hospital discharge

2 - Administering prescribed subcutaneous anticoagulants The LPN can administer prescribed subcutaneous anticoagulants to the patient because it is within his or her scope of profession. The RN, not the LPN, should monitor for adverse effects of anticoagulant use, provide instructions to the patient about the use of pressure to stop bleeding, and teach the patient about the use of elastic compression stockings during a hospital discharge.

A nurse performs assessments and plans care for the patients on a medical unit. What patient care can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. 1 Planning nursing actions for patient care 2 Helping the patients with bathing and hygiene 3 Measuring and recording the patients' vital signs 4 Evaluating a patient's orientation to time and place 5 Providing patient education about the prevention of disease

2 - Helping the patients with bathing and hygiene 3 - Measuring and recording the patients' vital signs Unlicensed assistive personnel (UAP) may be delegated activities that do not require nursing judgment. Helping the patient with bathing and measuring and recording vital signs are routine tasks that can be performed without advanced nursing education and training, and thus can be delegated to UAP. Evaluation of the patient's awareness requires assessment and should not be delegated to UAP. Planning nursing actions requires nursing judgment and should not be delegated to UAP. Patient teaching should not be delegated to UAP because it requires advanced knowledge of the teaching and learning process.

What may be the consequence of failure to advocate for a patient whose care is compromised by health care disparities? 1 No action 2 Legal action 3 Moral obligation 4 Health discrimination

2 - Legal action Failure to advocate for a patient who is experiencing health care disparities can result in legal action. The nurse must advocate on behalf of the patient; taking no action is inappropriate. A moral obligation is a duty one owes, but is not legally held accountable for. Discrimination is based on a patient's race, ethnicity, body size, sexual orientation, or ability to pay and will likely result in less aggressive or negative treatment practices.

In order to focus on more complex patient care needs and deliver efficient, economic care to the patients, which task may the nurse delegate to an unlicensed assistive personnel (UAP)? 1 Discharging a patient 2 Measuring urine output 3 Administering oral medications 4 Performing an initial assessment

2 - Measuring urine output The delegation and assignment of nursing activities is a process that, when used appropriately, can result in safe, effective, and efficient patient care. Delegating can allow the nurse more time to focus on complex patient care. State boards of nursing and agency policies identify activities that may be delegated to a UAP. Measuring urine output is a task that may be delegated to a UAP. Discharging a patient, administering oral medications, and performing an initial assessment are nursing interventions that require independent nursing knowledge, skill, and judgment, and therefore cannot be delegated to a UAP.

Which task could the registered nurse delegate to unlicensed assistive personnel (UAP) during the care of a patient who has had recent transverse rectus abdominis musculocutaneous (TRAM) flap surgery? 1 Document the condition of the patient's incisions. 2 Mobilize the patient in a slightly hunched position. 3 Change the patient's abdominal and chest dressings. 4 Change the parameters of the patient-controlled analgesic (PCA) pump.

2 - Mobilize the patient in a slightly hunched position. Mobilization of a postsurgical patient may be delegated, and the patient who has had a TRAM flap should not stand or walk fully erect to minimize strain on the incisions. Changing dressings, assessing wounds, and reprogramming a PCA pump are not appropriate tasks to delegate to UAP.

Which task can the registered nurse (RN) delegate to an a properly trained unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? 1 Assessing the need for suctioning 2 Suctioning the patient's oropharynx 3 Assessing the patient's swallowing ability 4 Maintaining appropriate cuff inflation pressure

2 - Suctioning the patient's oropharynx If the UAP have been trained in correct technique, UAP may suction the patient's oropharynx. Assessing the need for suctioning should be performed by an RN or licensed practical nurse, whereas swallowing assessment and the maintenance of cuff inflation pressure should be performed solely by the RN.

A patient has provided an informed consent for an elective tubal ligation under general anesthesia. The nurse recalls that the patient can revoke the consent for the surgery at what stage? Select all that apply. 1 After the surgery has started 2 When the patient is partially informed 3 Just before the scheduled surgery time 4 After the patient has signed the consent form 5 When the patient is in the preoperative holding area

2 - When the patient is partially informed 3 - Just before the scheduled surgery time 4 - After the patient has signed the consent form 5 - When the patient is in the preoperative holding area The patient can revoke the consent at any time before the scheduled surgery. The patient can refuse the surgery even when she is in the preoperative holding room, assuming she is conscious and able to make the decision for herself. The informed consent can be revoked whether she has received full or partial information, even at the very last minute. Once the surgery has started and the patient is under general anesthesia, obviously she will not be able to revoke the consent.

The registered nurse (RN) is providing care to a patient who requires a bladder irrigation after a transurethral resection of the prostate (TURP) to treat benign prostatic hyperplasia (BPH). Which interventions should the nurse delegate to the licensed practical nurse (LPN) who is assigned to the patient's care team? Select all that apply. 1 Assessing patency by measuring intake and output 2 Implementing manual irrigation for bladder spasms 3 Administering prescribed antispasmodics as needed 4 Monitoring catheter drainage for increased blood or clots 5 Increasing the flow of the solution to maintain a light pink color of the outflow

3 - Administering prescribed antispasmodics as needed 4 - Monitoring catheter drainage for increased blood or clots 5 - Increasing the flow of the solution to maintain a light pink color of the outflow Administering prescribed antispasmodics; monitoring catheter drainage for increased blood or clots; and increasing the flow of the irrigating solution in order to maintain a light pink color of the outflow are tasks that can safely be delegated to the LPN. The RN is unable to delegate an assessment of the catheter patency by measuring intake and output since this is a nursing assessment and assessment cannot be delegated to the LPN. Similarly, implementing manual irrigation is out of the LPN's scope.

When caring for a critically ill patient on mechanical ventilation, what task must the registered nurses (RNs) perform by themselves and not delegate to unlicensed assistive personnel (UAP)? 1 Obtaining vital signs 2 Measuring urine output 3 Administering sedatives 4 Performing bedside glucose test

3 - Administering sedatives While caring for a patient requiring mechanical ventilation, the registered nurses (RNs) must administer sedatives by themselves; they should not delegate this task to unlicensed assistive personnel (UAP). UAP can be tasked with obtaining vital signs, measuring urine output, and performing bedside glucose tests.

In caring for the postoperative patient on the clinical unit after transfer from the postanesthesia care unit (PACU), which care can be delegated to the unlicensed assistive personnel (UAP)? 1 Monitor the patient's pain 2 Do the admission vital signs 3 Assist the patient to take deep breaths and cough 4 Change the dressing when there is excess drainage

3 - Assist the patient to take deep breaths and cough The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The registered nurse (RN) should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The licensed practical nurse (LPN) or RN will monitor and treat the patient's pain and change the dressings.

Delegation is an important aspect of nursing leadership. Which activities are appropriate for a nurse to delegate to the LPN? Select all that apply. 1 Gathering data and determining nursing diagnoses 2 Initial assessment of a patient admitted to long-term care 3 Measuring intake and output for a patient with dehydration 4 Changing a wet-to-dry dressing in the long-term care setting 5 Teaching a diabetic patient how to administer an insulin injection

3 - Measuring intake and output for a patient with dehydration 4 - Changing a wet-to-dry dressing in the long-term care setting Delegable tasks are those which do not require independent nursing knowledge, skill, or judgment. The nurse can delegate tasks to the LPN in stable, routine situations such as obtaining and recording a patient's intake and output or routine dressing changes on stable patients. Examples of tasks that cannot be delegated include initial assessments, determining nursing diagnoses, patient teaching, and evaluating patient care outcomes.

When reviewing the preoperative forms, the nurse notices that the informed consent form is not signed. What is the best action for the nurse to take? 1 Have the patient sign a consent form. 2 Have the family sign the form for the patient. 3 Notify the health care provider to obtain consent for surgery. 4 Teach the patient about the surgery and get verbal permission.

3 - Notify the health care provider to obtain consent for surgery. The informed consent for the surgery must be obtained by the health care provider. The nurse can witness the signature on the consent form and verify that the patient (or caregiver if patient is a minor, unconscious, or mentally incompetent to sign) understands the informed consent. Verbal consents are not enough. The state's nurse practice act and agency policies must be followed.

The student nurse asks the nursing instructor what advocacy means in terms of patient care. What is the instructor's best response? 1 "Advocacy means the nurse has the knowledge to carry out tasks safely." 2 "Advocacy means the nurse does everything possible to keep the patient happy." 3 "Advocacy means the nurse ensures all patient information is kept confidential." 4 "Advocacy means the nurse acknowledges and protects the rights of patients."

4 - "Advocacy means the nurse acknowledges and protects the rights of patients." The nurse educator best describes advocacy as acknowledging and protecting patient rights. Keeping patients happy is a superficial task that does not ensure patient rights are protected. Assuring all patient information is kept confidential is part of the Health Insurance Portability and Protection Act (HIPAA). Assuring HIPAA is followed may be considered part of patient advocacy, but it is not the best definition. Competency means the nurse has the knowledge to carry out tasks safely.

A registered nurse (RN) on a general medical-surgical unit is delegating tasks to a unit licensed practical nurse (LPN). The RN just received four new prescriptions from a healthcare provider. Which task is the RN able to delegate to the LPN as permitted by the state nurse practice act? 1 Administering a saline infusion to a client with diabetic ketoacidosis 2 Assessing a client with heart failure who has signs of fluid overload 3 Determining if an intravenous infusion should be given to a client with an acid-base imbalance 4 Decreasing the rate of an existing intravenous infusion for a client about to be discharged home

4 - Decreasing the rate of an existing intravenous infusion for a client about to be discharged home Depending on the state's nurse practice act, an LPN can adjust the intravenous infusion rate for stable clients. A client about to be discharged home is considered stable. Clients with diabetic ketoacidosis, acid-base imbalance, and fluid overload are not considered stable, so tasks related to intravenous infusions and fluid status for these clients cannot be delegated to the LPN.

If a patient cannot afford medical supplies, what responsibility does the nurse have to advocate for this patient? 1 Health equity 2 Utilitarianism 3 Moral obligation 4 Ethical obligation

4 - Ethical obligation When disparities are observed in an individual patient or a family, professional nurses are ethically and legally responsible for patient advocacy. Health equity is achieved when every person has the opportunity to attain his or her health potential, and no one is disadvantaged. Utilitarianism is action for the greater good. A moral obligation is a duty that one owes but is not legally bound to fulfill.

The Health Insurance Portability and Accountability Act (HIPAA) is part of federal legislation that addresses what? 1 Sentinel events 2 Monitoring of Medicaid fraud 3 Computerized provider order entry (CPOE) 4 How protected healthcare information (PHI) is used

4 - How protected healthcare information (PHI) is used HIPAA is part of federal legislation that addresses how protected healthcare information is used. The Joint Commission monitors sentinel events. Medicaid fraud is monitored by several agencies, including the State Medicaid Agencies and the Medicaid Fraud Control Units. CPOE was initiated to assist in preventing errors, increasing patient safety, and streamlining workflow.

The nursing process is an organized framework to provide patient-centered care. Which nursing phase should the nurse use to identify health problems? 1 Planning 2 Evaluation 3 Assessment 4 Nursing diagnosis

4 - Nursing diagnosis The nursing diagnosis is helpful for identifying health problems. It is used to analyze the assessment data and make a judgment about the nature of the data. It includes labeling human responses to actual or potential health problems or life processes. During planning, the nursing diagnosis directs the development of patient outcomes or goals. It helps in identification of nursing interventions to accomplish the outcomes. Evaluation is a continual activity in the nursing process. Assessment is the process of collecting subjective and objective information about the patient.

Which represents a Health Insurance Portability and Accountability Act (HIPAA) violation using social networking? 1 Posting a picture of the staff on the unit 2 Posting a statement about working overtime 3 Posting a statement about how busy it is on the unit 4 Posting a statement about a patient who came into the emergency department (ED) with a gunshot wound

4 - Posting a statement about a patient who came into the emergency department (ED) with a gunshot wound Posting a statement about a patient who came into the ED with a gunshot wound is a HIPAA violation. Posting a picture of the staff on the unit, a statement about how busy the unit is, or working overtime are not HIPAA violations. However, taking photos with a cell phone on the unit may be against hospital policy.

2 - Patient B The registered nurse can safely delegate adjustment of the O2 level for stable patients. In this case, the patient with COPD has stable vital signs, and while the SaO2 is low, it would be considered an acceptable level for a COPD patient. It is the responsibility of the RN, not LPN, to teach patients about inhaler use, as for Patient A; evaluate responses to therapy, as for Patient C; or complete a respiratory assessment, as for Patient D.

The registered nurse (RN) working on a pulmonary floor is delegating tasks to a licensed practical nurse (LPN). Which patient intervention can appropriately be delegated to the LPN? 1 Patient A 2 Patient B 3 Patient C 4 Patient D