EAQ's

While responding to a fire in a healthcare facility, which intervention made by the facility personnel would the nurse feel is inappropriate?

While responding to a facility fire, facility personnel should not risk injury to self or staff members while moving clients or attempting to extinguish the fire. The facility personnel are trained to direct the ambulatory clients to walk to a safe location during any disaster. The immediate intervention of the facility personnel during fire disaster would be removing any clients or staff from danger of fire or smoke. Bedridden clients can be moved by carrying them on blankets along with one or two staff members.

The registered nurse (RN) is getting ready to leave the client care unit for a lunch break. The RN asks the LPN to take care of a client during the lunch break. Which concept is emphasized in this situation?

Delegation is the concept of a transfer of authority between two people to perform some type of task, e.g., between an RN and licensed staff. Leadership is the action of leading a group or an organization. Supervision is defined as the active process of directing, guiding, and influencing the outcome of an individual's performance. Assignment is the transfer of both accountability and responsibility.

Which individual is categorized as one who would be considered as "dependent status"?

Licensed practical nurses (LPNs) who work under the direction of a registered nurse (RN) or a physician have dependent status. The unit secretary does not have a legal recognition. The nurse manager is an individual who is answerable to the designated delegator. The RN as a delegator assigns the work to LPNs.

A client is scheduled for a below-the-knee amputation. When should the nurse begin rehabilitation planning for the client?

Rehabilitation should begin immediately. This includes preoperative discussion of the nature of the operation and rehabilitation techniques. During the convalescent phase, on discharge from the hospital, and when it is time for a prosthesis are too late; valuable rehabilitation time has been wasted.

Which theory emphasizes that leadership effectiveness depends on the executive nurse's interpersonal skills?

Situational-contingency theories, which are leadership theories, hold that leadership effectiveness depends on a leader's interpersonal skills. The hierarchy of needs explains that people are motivated first by physiological needs and safety, then by social and self-actualizing needs. Transformational leadership is a process through which the leader attends to the needs and motives of followers. OB modification theory says that the leader should use positive reinforcement to motivate followers and avoid situations that cause discomfort.

A client after a trauma has difficulty opening his or her eyes to pain, has abnormal flexion motor response, and speaks inappropriate words. What is the status of the client utilizing the Glasgow Coma Scale? Record your answer using a whole number.

The client having pain opening the eyes scores 2 points, abnormal flexion motor response scores 3 points, and inappropriate words scores 3 points, which adds up to 8. A client scoring 8 points on the Glasgow Coma Scale after trauma requires medium priority.

A registered nurse (RN) delegates a task to a licensed practical nurse (LPN). What should the RN do when the LPN executes the task improperly?

The delegator should provide constructive and positive, yet honest, feedback about the work of the delegatee. A verbal attack will destroy the relationship between the delegatee and delegator. The RN would lose credibility by conveying satisfaction with the delegatee's work, which is not satisfactory. Ignoring the task and not giving feedback will not promote a healthy relationship.

The registered nurse (RN) who was caring for a postsurgical client went out for a break. The RN assigns the work to a healthcare professional who is also an RN. Which is the correct statement regarding this situation?

When the work is assigned to another registered nurse (RN), it indicates assignment. The RN holds responsibility and also accountability of the assigned task. When the work is assigned to other practitioners, it indicates only responsibility is transferred.

A client comes into the emergency room (ER) after hitting his head while playing basketball. He is alert and oriented. Which is a priority nursing intervention?

All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. ROM would be contraindicated at this time. The head CT would be prescribed next. The airway does not need to be opened because the client appears alert and not in respiratory distress. In addition, the head-tilt chin-lift maneuver would not be used until the cervical spine injury is ruled out.

A nurse who is assigned to care for a 6-month-old infant with diarrhea is reviewing the infant's medical history, assessment findings, laboratory reports, and practitioner prescriptions. The infant weighs 15½ lb (7 kg). The healthcare provider has written a prescription for potassium chloride to be added to the IV fluids. What assessment finding signals the nurse to question this prescription?

An infant weighing 15½ lb (7 kg) should have a minimum urine output of 1 mL/kg/hr, or 7 mL/hr. This infant's output is only 2 mL/hr. Decreased urine output will result in retention of potassium, causing hyperkalemia. Intractable crying is the expected response of an ill 6-month-old infant. Inadequate tissue turgor is an indication of dehydration, which is the reason for the IV infusion. There is no reason to question the prescription for the oral fluid intake amount because the IV infusion is supplementing the oral rehydration therapy.

A client is admitted to the hospital because of multiple chronic health problems. What is the priority intervention at this time?

Collaboration of all team members involved in the client's care early during hospitalization will allow for efficient planning of care and help prepare for discharge. The client may or may not be ready to join a support group at this time. Assuring the family that staff members will take care of the client's needs may promote dependence. The client should be encouraged to assume self-care gradually. Although this should be done eventually, it is not the priority at this time.

The nursing manager is evaluating the actions of charge nurses on different units of the hospital. Which charge nurse is providing high-quality care to the clients?

Cost-effective and patient-centered care helps provide high-quality care to the client. Therefore the nurse should be able to work with fewer resources to reduce the cost of treatment. The nurse should ensure that the transition of clients between the departments is respectful, coordinated, and efficient to provide patient-centered care. Thus charge nurse B is providing high-quality care to the client. The nurse should act within the scope of his or her practice and should not adjust the dose of the medications because that is the role of primary healthcare provider. Thus charge nurse A is not providing high-quality care to the clients. As outpatient surgery does not require an overnight hospital stay, the client can go home within 24 hours. So, charge nurse C working in the outpatient surgery unit should ensure that the client is discharged within 24 hours. The nurse should take preventive measures to prevent the risk of fall and accidents. Therefore charge nurse D should not place a table and chair near the client's bed side because the client may fall accidentally.

A nurse uses flow charts to determine the usefulness of bed-monitoring devices for checking on dementia clients. Which Quality and Safety Education for Nurses (QSEN) competency does the nurse comply with?

According to QSEN competencies, quality improvement takes place when the nurse uses data to monitor the outcomes of care provided to improve the quality and safety of health care systems. In the given scenario, the nurse uses flow charts to determine the usefulness of applying bed-monitoring device for dementia clients in order to improve the quality of client care.

A nurse manager promotes a staff nurse to assistant manager of the medical unit as the staff nurse had expressed interest in taking on more responsibilities. Which type of ethical principle is exhibited by the nurse manager by this activity?

According to ethical principles, beneficence states that the actions one takes should promote good; it is the basic obligation to assist others. Therefore, by employing this principle, the nurse manager as a leader is encouraging employees to seek more challenges in clinical experiences and to take on additional responsibilities. Fidelity means fulfilling the promises or commitments made to others. Autonomy is the activity of addressing personal freedom and self-determination. Paternalism may be used to assist people in making decisions when they do not have sufficient data or expertise.

Which care activities would be involved in a correct delegation process? Select all that apply.

Activities such as cleaning the client's body and assisting the client with oral feeding can be performed by the licensed practical nurse (LPN) and unlicensed assistive personnel (UAP). It is always the responsibility of the registered nurse (RN) to guide the UAP while performing any activity. The UAP is not allowed to perform activities such as providing medication. The LPN should not evaluate the client condition; it is the responsibility of the RN.

Which is an indirect nursing care intervention?

Indirect nursing care interventions are treatment actions not performed directly to the client but are done to aid the client. Indirect care intervention includes managing the client's environment. Direct care interventions include administration of medications, counseling the family during a time of grief, and insertion of an intravenous infusion.

A nursing student is evaluating different scenarios that are examples of following the basic health care principles. Which scenario is an example of following the principle of justice?

Just culture is an aspect of the principle of justice. Encouraging discussion of mistakes or near mistakes without the fear of recrimination helps in fostering a just culture. The principle of autonomy refers to the commitment to include clients in the decision-making process. Obtaining the client's consent before performing a vital surgery shows a respect for the client's autonomy. The principle of nonmaleficence states that the nurse should do no harm. As such, the nurse should weigh the benefits of a treatment against its adverse effects, as when determining whether a backrub will be the best pain-relief measure for a client with a spine injury. The principle of fidelity requires the nurse to keep health care promises made to the client. Since the client is in spiritual distress, the nurse summons the hospital chaplain to provide spiritual help.

After an earthquake, the emergency medical service (EMS) providers' team is performing triage functions in the field. How would the nurse describe how the EMS teams categorize the triage of clients? Select all that apply.

Most mass casualty response teams both in the field and in the hospital setting use a disaster triage tag system that categorizes triage priority by number and color. Facility staff may assist ambulatory clients to the hospital but that does not mean that those clients should be treated before others. Clients brought in an unconscious state may not have their priority correctly assigned because unconsciousness may be due to many reasons. Conditions such as severe hemorrhage in clients are categorized with the appropriate tag.

A primary healthcare provider prescribes propylthiouracil (PTU) for a client with hyperthyroidism. Two months after being started on the antithyroid medication, the client calls the nurse and complains of feeling tired and looking pale. What should the nurse do?

The client should be examined by the primary healthcare provider, and blood tests should be prescribed; anemia may result from the bone marrow depressant effect of PTU. Advising the client to get more rest is unsafe; a physical examination and blood tests are necessary to determine the cause of the client's fatigue and paleness. It is unsafe to skip one dose of PTU daily without a primary healthcare provider's prescription; advising the client to alter the dosage of a drug is not within the legal role of the nurse. It is unsafe to increase the dose of PTU without a primary healthcare provider's prescription; advising the client to alter the dosage of a drug is not within the legal role of the nurse.

A registered nurse is teaching a group of student nurses about concepts of triage in a mass casualty incident. Which statement of the student nurse indicates effective learning?

The disaster triage tag system classifies the triage priority by color and number. The green tag is for class III clients who are nonurgent or walking wounded. A black tag is issued to class IV clients who are expected to die. A yellow tag is issued to clients who do not require urgent treatment and the treatment can be delayed for some time. A red tag is used for clients who require emergent treatment.

What is the priority nursing action for a scorpion bite?

The first priority is vital sign assessment for a client who sustained a scorpion sting. Continuous monitoring for several hours in the critical care unit helps to ensure the client's safety. The nurse has to then apply an ice pack to the sting site to reduce pain. The poison control center assists with client management, particularly in regard to the use of medications for scorpion stings, and this is a medium priority. Covering the client with cooling blanket to reduce fever is of lowest priority.

The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a client who is experiencing hypovolemic shock due to a penetrating wound?

The nurse would use a red tag for a client who has injuries that are an immediate threat to life, such as hypovolemic shock, during mass casualty conditions. A black tag is used for a client who is expected and allowed to die. A green tag is used for a client with minor injuries that do not require immediate treatment. A yellow tag is used for a client who has major injuries requiring treatment.