exam 1 concepts

which purposes are accomplished by applying the four elements of safety, critical thinking, stability, and time in the delegation tasks?

encouraging effective delegation decisions, ensuring effectiveness in performing elements of care, assessing the ability of unlicensed assistive personnel (UAP) to perform the task

after presenting information about fall risk assessments to nursing staff, which participant's statement needs review for corrective action?

"we will use the admission fall assessment for the entire stay"

according to maslow's hierarchy of needs in which order would the nurse prioritize actions?

1. providing a warm bath to the client to promote a good night's sleep 2. encouraging the client to talk about fears and feelings 3. assisting the client in getting out of bed to join family members for meals 4. praising a client for administering insulin correctly

in the case of a client with which condition would it be most safe for the nurse to delegate the task of vs obtainment to an unlicensed assistive personnel (UAP)

ankle sprain

which data would the nurse use to determine a client's score on the braden scale to predict a client's risk for developing pressure injuries?

anorexia, hemiplegia, history of diabetes, urinary incontinence

the nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. which step would the nurse do next after placing the nurse's arms under the client's acillae?

bending and then straightening their knees

which strategies will promote safety and quality of client care on the unit? select all that apply.

communicate with clarity and precision when designing multidisciplinary plans of care, create a safety huddle so all hcp's are aware of the clinical objectives, conduct communication simulations to increase knowledge about expertise of other health care disciplines

A nurse is transferring a client from the bed to the chair. which action would the nurse take first during the transfer?

instruct the client to dangle the legs

Which needs would the nurse address using Maslow's hierarchy of needs when caring for an emancipated minor reporting improper nutrition?

physiological

which physiological factor increases the risk of falls for a toddler?

poorly developed depth perception

which member of the health care team is responsible for consulting other hcp's in planning and delivering client care?

primary nurse

which action by the nurse increase safety in the clinical setting? select all that apply.

remain current with evidence and best practices, use only quality resources (especially websites), report faulty equipment as soon as discovered

which example mentioned by the nurse belongs to the 5th level of maslow's hierarchy of needs? select all that apply

"a client wishes to become the best swimmer in the whole world" "a client tells the nurse that he or she wishes to complete college edu" "a client who is bedridden requests a physical therapist consultation to achieve maximum mobility"

while assessing a client's hair, the nurse notices the client has head lice. the nurse teaches the client about hair hygiene and lice control. which client statement indicates an understanding of the teaching? select all that apply

"i will clean my comb in ammonia water" "i should use a dilute vinegar solution to loosen the units" "i should use a shampoo treatment once every 24 hours"

A newly promoted registered nurse (RN) is about to start delegation for the first time in her career. Which experiences foster professional self-confidence in the early career stage for an RN? Select all that apply.

experience in clinical delegation, application to theory of practice, development of clinical judgement, engagement with a nursing mentor

which activities would the nurse preform to meet the clients safety and security needs based on maslow's hierarchy of needs? select all that apply.

positioning the bed in a low position and keeping the side rails up, monitoring vs (bp to decrease risk of falls), observing a client who has suicidal tendencies to prevent adverse incidents

The nurse plans to help a client get out of bed for the first time after surgery. Which assessment would the nurse complete before having the client sit on the side of the bed? Select all that apply

presence of safe footwear, status of comfort and pain, appearance of would and skin, patency of urinary catheter

while hospitalized a client with diabetes is observed picking at calluses on the feet. which intervention would the nurse implement immediately?

teach the client the importance of effective foot care

which point regarding ethics and values requires further edu?

the american nurses association (ANA) code of ethics ensures that the code remains constant

which statements related to initial assessment of bp by the nurse requires correction? select all that apply

the stethoscope is applied too firmly against the anticubital fossa will show a low systolic reading, having the client's arm unsupported while assessing bp will result in a false low reading of bp

which nursing action illustrates the quality and safety edu for nurse (QSEN) competency called informatics?

use information and technology to communicate, manage knowledge, migrate errors and support decision making

which action would be included in an organization's policy for hand hygiene? select all that apply

wash hands before applying sterile gloves, wash with either soap and water or alcohol-based hand rub before client contact, wash with soap and water when hands are visibly soiled with blood, wash with ABHR if hands are not visibly soiled

the nurse teaches a client about wearing thigh-high anti-embolism elastic stocking. which instruction would be correct to include?

you will need to apply them in the morning before you lower your legs from the bed to the floor

which instructions would the nurse give to an older adult with decreased perception of touch?

"hold onto handrails while ambulating" "look where your feet are placed while walking" "wear shoes that give good support while walking" "if you are unable to change your position frequently, request assistance"

the nurse delegates the task of caring for a postpartum client. During assessment the nurse observes an infection in the client caused by lack of hygiene. Which member of the healthcare team is most likely responsible for the clients condition? Select all that apply

RN AND UAP