Final

A nurse manager expects the unit nurse leader to oversee a staff of mature adults who work best as a team. Which type of leader would be most suitable for the group? A. Autocratic leader B. Situational leader C. Permissive leader D. Democratic leader

Answer: D Democratic leadership is a people-centered approach that emphasizes team building and collaboration through the joint effort of all team members. This leadership works best with mature employees who work well as a group. Autocratic leadership is important in emergency situations where immediate decisions are required. Situational leadership is a comprehensive approach that takes into account the style of the leader, the group being managed, and the situation at hand. In permissive leadership, the leader completely relinquishes control. These two leadership styles would not be appropriate for mature adults who can work as a team.

An RN delegates to the LPN to administer a scheduled tube feeding to a patient. The RN has now transferred full accountability to the LPN for the task getting done, and the RN is no longer accountable for the task. True or False

FALSE The RN can delegate this task to the LPN BUT the RN is still ACCOUNTABLE for the task getting done even though the RN is not the one performing it.

The nurse is taking care of a client preoperatively. The client is NPO and an intermediate and short-acting insulin are scheduled for 0700 daily. The client's surgery is scheduled for 0900. Which is the best action for the nurse to take? A. Administer both medications. B. Obtain and document the client's finger stick glucose level. C. Call the primary health care provider (PHCP) for clarification. D. Withhold both medications and document surgery as a reason for withholding the medication.

Answer C: The diabetic client who is going to surgery will not have the usual diet and will not require the routine prescribed insulins. The primary health care provider should be notified to prescribe an adjusted insulin dosage for the day of surgery. The nurse must contact the PHCP for clarification of the prescription and should not give the medication because it might lead to hypoglycemia during surgery. The nurse should not withhold the insulin because this might lead to hyperglycemia during surgery and can cause increased risk for infection and impaired wound healing. The nurse may obtain the finger stick glucose reading but this should be reported to the PHCP when seeking clarification. Focus on the strategic word, best. Think about the preoperative care for clients with diabetes mellitus. Recalling the effects of insulin and the nurse's legal responsibilities and role will assist in directing you to the correct option.

Nurses on a unit provide personal hygiene, administer medications, educate the patient and family about treatments, and provide emotional support. These nurses provide patient care based on which nursing delivery system? A. Total patient care B. Partnership nursing C. Team nursing D. Functional nursing

Answer: A In total patient care nurses provide all aspects of patient care.

A client with arthritis is scheduled for a surgical knee joint replacement. The client will be admitted to the hospital on the day of the surgical procedure, and the nurse is reinforcing instructions with the client regarding preparation for the surgical procedure. Which client statement indicates an understanding of the preoperative instructions? A. "I cannot drink or eat anything after midnight on the night before surgery." B. "I need to discontinue my prescribed knee exercises at least 1 week before surgery." C. "I need to stop taking my prescribed prednisone 48 hours before the scheduled surgery." D. "My last dose of prescribed acetylsalicylic acid should be taken the evening before surgery."

Answer: A Preoperative instructions are important so that the client is readied adequately for surgery and all has been done to achieve a successful outcome. The client must understand the importance of following the timing of being NPO to lower the risk of aspiration associated with the anesthetic. Antiplatelet medications such as aspirin alter normal clotting factors and increase the risk of hemorrhage. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. Prednisone, a corticosteroid, should not be discontinued abruptly. In fact, additional dosages of the corticosteroid may be necessary before stressful situations, such as surgery. There is no reason to discontinue prescribed exercises, and discontinuing exercises in this client may be harmful.

What postoperative assessment would indicate to the nurse a change in a client's cardiovascular status? (SELECT ALL THAT APPLY) a. Capillary refill time greater than 3 seconds b. Vomiting moderate amount of green emesis c. Absent gag reflex d. Pedal pulse non-palpable e. Dropping blood pressure

Answer: A, D, E Changes in cardiovascular status affect blood​ pressure, pulses, and capillary refill. Dropping blood​ pressure, non-palpable pedal​ pulse, and capillary refill time greater than 3 seconds reflect a change in the cardiovascular status. An absent gag reflex indicates a change in a protective neurological reflex. Vomiting indicates a change in gastrointestinal status.

A hospital converts to a system of care delivery in which RNs, LPNs, and unlicensed assistive personnel (UAP) are responsible for implementing a specific task, such as medication administration or personal hygiene, for the entire nursing unit. This type of delivery system is: A. total patient care B. functional nursing C. team nursing D. primary nursing

Answer: B In functional nursing members of the team are assigned specific tasks such as assessment or medication administration.

A patient is admitted for a hysterectomy, and the RN develops and implements the plan of care but also delegates to the LPN/LVN the responsibility of administering oral medications. While off duty, this RN receives a call requesting a change in the plan of care because the patient has developed deep vein thrombosis. The nurse who originally planned the care is practicing which type of nursing care delivery? A. Modular B. Primary C. Team D. Functional

Answer: B The primary nurse assumes 24-hour responsibility for planning, directing, and evaluating the patient's care from admission through discharge but may delegate or provide primary care during the shift when present.

The nurse is conducting the preoperative assessment. The client reports having a cup of black coffee before arriving for the scheduled surgery. What should the nurse do with this information? a. Instruct the client to refrain from further intake b. Administer the preoperative medication c. Notify the surgeon d. Document the fluid intake in the medical record

Answer: C The nurse should notify the surgeon with the information if the client has had anything to eat or drink within 8 hours prior to​ surgery, because this increases the​ client's risk of aspiration. The surgical procedure will be​ cancelled, especially if the surgery is elective. The client should not be given the preoperative medication until the surgeon in notified of the fluid intake. The nurse needs to do more than document the information in the medical record. The client should have been instructed to refrain from food or fluids for 8 hours before the surgery prior to arriving to the hospital for the procedure.

The nurse is preparing a client for a right below-the-knee amputation. The nurse anticipates that the client is likely to experience which psychosocial problems in the perioperative period? Select all that apply. A. Pain B. Anger C. Grief D. Anxiety E. Altered body image

Answer: C, D, E A client facing an elective amputation of a lower extremity will experience psychosocial as well as physical challenges during the perioperative period. The client is likely to experience grief because of the loss of the extremity as well as an alteration in body image. The client will also experience anxiety since this will be a new experience and life as an amputee is unknown. Pain is a physical problem influenced by psychosocial factors. There are no data in the question to support a problem of anger. Focus on the subject, a client's psychosocial reaction to an amputation surgery. Noting the word psychosocial will direct you to consider the common reactions to an amputation, loss of a body part, and facing uncertainty. Remember to focus on client concerns as a priority in the perioperative period.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? A. Inhale as rapidly as possible. B. Keep a loose seal between the lips and the mouthpiece. C. After maximum inspiration, hold the breath for 15 seconds and exhale. D. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

Answer: D For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly. Focus on the subject, correct use of an incentive spirometer, and visualize the procedure. Note the words rapidly, loose, and 15 seconds in the incorrect options. Options 1, 2, and 3 are incorrect steps regarding incentive spirometer use.

The nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which is the appropriate initial nursing action? A. Leave the incision open to the air. B. Apply a dry sterile dressing to the wound. C. Ask the client to cough to verify the presence of dehiscence. D. Apply a sterile dressing soaked with sterile normal saline to the wound.

Answer: D Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. It usually occurs 6 to 8 days after surgery. The client should be instructed to remain quiet and to avoid coughing or straining. The client should be placed in semi-Fowler's position to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The primary health care provider needs to be notified immediately. Note the strategic word, initial, and focus on the subject, wound dehiscence. Eliminate option 1 because this action would expose the open wound and underlying tissues to infection. Eliminate option 2 because a dry dressing will irritate the exposed body tissues. Eliminate option 3 because coughing will disrupt the exposed underlying tissue and organs.

The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all that apply. A. Wound care B. Personal hygiene C. Activity restrictions D. Frequent assessment of vital signs E. Coughing and deep breathing exercises F. Pain monitoring and medications to relieve pain

Answer: D, E, F Rationale: The type of planning and instruction required varies with each individual and type of surgery. Preoperative education, including rationales related to a client's expected postoperative behavior, has a positive outcome on recovery and prevention of postoperative complications. Postoperatively, the client will be monitored closely with vital signs and the client should understand this is routine. General anesthesia predisposes clients to respiratory problems that can lead to atelectasis and pneumonia in the postoperative period. Therefore, coughing and deep breathing are important exercises to be taught in the preoperative period. Addressing that pain will be monitored and controlled with prescribed analgesia should allay client fears regarding pain. Specific instructions that the client needs to receive before discharge should include wound care, activity restrictions, dietary instructions, postoperative medication instructions, personal hygiene, and follow-up appointments. Test-Taking Strategy: Options 1, 2, and 3 refer to information that needs to be taught postoperatively. Options 4, 5, and 6 refer to information that should be taught preoperatively.

As the registered nurse, which tasks below should you NOT delegate to the LPN? A. Performing an assessment on a new admission B. Collecting a urine sample from an indwelling Foley catheter C. Developing a plan of care for a patient who is admitted with Guillain-Barré Syndrome D. Educating a patient about how to monitor for side effects associated with Warfarin E. Auscultating lung and bowel sounds F. Starting a blood transfusion G. Administering IV Morphine 2 mg for pain H. Providing wound care to a stage 3 pressure injury

Answers are A, C, D, F, G These are all out of the scope of practice for an LPN. Remember anything that deals with assessments, educating, evaluating, developing a plan of care, IV medications, unstable patients, or invasive/complex procedures where there is unpredictability the RN is responsible for doing it, and these tasks can't be delegated.

On your unit there are two RNs: one is a new RN while the other is an experienced RN. In addition, there are three LPNs and two nursing assistants. Which tasks delegated to one of the nursing assistants by the new RN needs to be re-evaluated? A. Apply hydrocortisone cream to eczema on skin after giving the patient a bath. B. Assist the patient with administering a Fleet Enema. C. Empty an ostomy bag. D. Collect and record patient's blood pressure, heart rate, temperature, oxygen saturation, respirations, and pain rating. E. Assist a patient with ambulating.

Answers: A, B Option A is a task for an LPN or RN because hydrocortisone cream is a medication and the nursing assistant cannot administer medications. Option B is a task for an LPN or RN because it is also a medication.