RN Lesson 1

An elderly client is admitted to a home care agency following hospitalization for exacerbation of heart failure. The client lives alone, has difficulty completing activities of daily living (ADLs) and is unable to drive. Reorder the steps in the case management process by dragging and dropping the options below.

1. Assessment of biophysical and sociocultural considerations 2. Identification of nursing diagnoses 3. Referral to personal care attendant and transportation services 4. Reassessment of health status and ADL ability 5. Evaluation of progress towards client's goals

The registered nurse (RN) and the unlicensed assistive person (UAP) are caring for clients on a surgical unit. Which action(s) by the UAP warrant immediate intervention? (Select all that apply.) 1) The UAP empties the indwelling catheter bag for the client who had a transurethral resection of the prostate (TURP) yesterday 2) The UAP applies moisture barrier cream to the client's excoriated perianal area 3) The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate in the hall 4) The UAP applies a fingertip pulse oximeter on a client whose fingernail is painted dark blue 5) The UAP assists a client, who had a total knee replacement two days ago, to shave using a straight-edge razor

3, 4, 5 Rationale:The UAP can perform a number of nursing tasks, such as emptying an indwelling urinary catheter bag and applying moisture barrier cream after peri care. However, it is unsafe for the UAP to ambulate a client who recently received an IV push narcotic. Although UAP can shave clients, it is unsafe to shave someone using a straight-edge razor because a client who had knee replacement surgery is probably taking an anticoagulant; only an electric razor should be used. Pulse oximeter readings must be done on a finger that is warm and free from dark fingernail polish.

A client who is unconscious is brought to the emergency department by an ambulance. What document should the nurse give priority to when preparing the care for this client?

A notarized original of the advance directive brought in by the partner This document specifies the client's wishes of what actions are to be taken when the client becomes unable to make health care decisions. The advance directive often includes a living will and the power of attorney to whom will make the decisions for the client. The next document that would take precedent are the orders written by the heath care provider. The clinical pathways are used to evaluate the client's progress during therapy.

A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law?

Complete and accurate documentation of assessments and interventions The medical record is a legal document. Documentation should include all steps of the nursing process; it must be complete, accurate, concise and in chronological order. Inaccurate or incomplete documentation will raise red flags and may indicate the nurse failed to meet the standards of care. The attorney will review the medical record with the nurse before giving a deposition (sworn pretrial testimony). Above-average performance reviews could be considered supporting information. Certification is an "extra" based on the nurse's initiative; it is, however, unrelated to accurate charting.

A nurse manager suspects a staff nurse of substance use disorder (SUD). Which approach would be the best initial action by the nurse manager?

Consult with human resources personnel about the issue and needed actions The nurse manager needs to consult with human resources to determine the proper procedures for documenting and reporting the nurse's behavior. The nurse manager could also consult the EAP if one is available. If the staff nurse is also suspected of diversion, and a written policy exists, the nurse manager would follow these procedures. Attempts should be made to help the nurse with SUD by providing counseling and treatment for this disease.

A nurse can delegate a task to a team member by determining their responsibility through which of the following documents? (Select all that apply.) Nurse practice act ​​​​​​​Organization's standard of care Organization's job description

If the nurse is unclear about a task they can delegate then they may need to review the nurse practice act and/or their organization's standards of care or delegate job description. Although it is important that the team member accepts the task, that does not mean the task is an appropriate assignment for that team member. A team member's relationship to the client may determine if the nurse assigns the task or not, but the relationship does not tell you if it is an appropriate task.

The new graduate nurse interviews for a position in a nursing department of a large health care agency that uses the approach of shared governance. Which of these statements best illustrate the shared governance model?

Nursing departments share responsibility for client outcomes Shared governance or self-governance is a method of organizational design. It promotes empowerment of nurses to give them responsibility for client care issues and outcomes with other divisions in the agency.

The triage nurse identifies that a 16-year-old client is legally married and has signed the consent form for treatment. What would be an appropriate action by the nurse?

Proceed with the triage process in the same manner as any adult client Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this married client has the legal capacity of an adult. Otherwise, the age for legal signatures is 18 years of age.

SBAR

S = situation (a concise statement of the problem) B = background (pertinent and brief information related to the situation) A = assessment (analysis and consideration of options - what you found/think) R = recommendation (action requested/recommended - what you want)

The nurse, who is caring for a client with complex and unique health needs, describes the nature of the illness in an online social forum for nurses. Neither the client's real name nor any other personal identifiers are used. What, if any, consequence could result from posting this information online?

The nurse could be fired for breach of confidentiality Many health care facilities have adopted a social media policy; it is important to understand that nurses can be fired for posting personal information about clients online, because this is an invasion of privacy. In addition to being a HIPAA violation, the Health Information Technology for Economic and Clinical Health Act (HITECH Act) gives states attorneys the right to pursue violations of patient privacy.

A nurse has been assigned to four clients in the emergency department, with each client experiencing one of these conditions. Which client should the nurse check first? Tension pneumothorax with slight tracheal deviation to the right. Correct! Viral pneumonia with atelectasis Spontaneous pneumothorax with a respiratory rate of 38 Acute asthma with episodes of bronchospasm

Tracheal deviation indicates a significant volume of air being trapped in the chest cavity with a mediastinal shift. In tension pneumothorax the tracheal deviation is away from the affected side. The affected side is the side where the air leak is in the lung. This situation also results in sudden air hunger, agitation, hypotension, pain in the affected side and cyanosis with a high risk of cardiac tamponade and cardiac arrest.