Intro Exam 4
What are the purposes of applying the four elements of safety, critical thinking, stability, and time in delegation? Select all that apply. Encouraging effective delegation decisions Ensuring effectiveness in performing elements of care Determining the level of readiness according to Hersey Developing the expectations of individuals to accomplish safety Assessing the ability of unlicensed nursing personnel (UNP) to perform the task Rationale
Applying the four elements of safety, critical thinking, stability, and time creates an integrative process that encourages effective delegation decisions. Elements of implementation should be understood to ensure effectiveness in performing elements of care. These elements must be considered while assessing the ability of unlicensed nursing personnel (UNP) to perform the task. To determine the readiness of a delegate, factors such as ability and willingness should be assessed according to Hersey's model of leadership. Practice acts, position descriptions, and policies are the elements required to form the expectations for which the individuals in certain conditions are expected to be able to accomplish safety.
The terrorist attack event on the World Trade Center on September 11, 2001, resulted in mass casualties that led to changes in hospital and community disaster planning efforts. What would the nurse say was the impact of this technological external disaster on the emergency medical services (EMS) for improving the safety of the public? Select all that apply. Providing routine training to facility staff about hazardous materials Upgrading decontamination facilities and equipment to protect staff Making structural changes that would offer protection from utility failures Preparedness of healthcare facilities for pandemic infections, including influenza
Developing approaches for preparedness to nuclear, biologic, chemical (NBC) threats Rationale The technological external disaster event of September 11, 2001 and the resulting focus on terror threats had a great impact on the disaster planning efforts for improving the safety of the public. Emergency medical services (EMS) agencies and hospitals improved safety by providing routine training to staff about hazardous materials handling. Upgrades were made to decontamination facilities and equipment to protect staff. Approaches were designed to make the staff prepared for nuclear, biologic, and chemical (NBC) threats. Preparedness of healthcare facilities for pandemic infections resulted more from natural external disasters, such as Hurricane Katrina. Unfortunately, there still have not been sufficient structural changes that would offer protection from utility failures.
Which sedative-hypnotics are used to treat insomnia effects associated with a panic disorder? Select all that apply. Phenelzine Paroxetine Alprazolam Imipramine Clonazepam
Rationale Alprazolam and clonazepam are examples of benzodiazepines, a class of sedative-hypnotics used to treat clients with insomnia effects associated with panic disorders. Phenelzine is a monoamine oxidase inhibitor used to treat panic disorders and promote sleep. Paroxetine is a selective serotonin reuptake inhibitor used to treat panic disorders and promote sleep. Imipramine is a tricyclic antidepressant used to treat panic disorders and promote sleep.
A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. Which data should the nurse use to determine a client's score on this scale? Select all that apply. Age Anorexia Hemiplegia History of diabetes Urinary incontinence
Rationale Anorexia causes nutritional problems; nutrition is a category on the Braden Scale. Hemiplegia causes mobility problems; this affects the categories of mobility, activity, and friction on the Braden Scale. Clients with a history of diabetes can also have peripheral neuropathy, causing numbness or loss of sensation in the hands in feet; sensory perception is a category on the Braden Scale. Urinary incontinence causes moisture, a category on the Braden Scale. Age is not used in the Braden Scale.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse would monitor the client for which complications? Select all that apply. Hyperglycemia Infection Hepatitis Anorexia Dysrhythmias
Rationale Hyperglycemia related to the high concentration of dextrose in TPN is a common complication of this therapy and must be monitored for by the nurse. Another common complication is related to the central venous access that is needed for infusion of TPN. Catheter-related infection is frequently seen and must be monitored for by the nurse. Hepatitis is usually not associated with total parenteral nutrition. Anorexia often is present before the medical decision is made to begin total parenteral nutrition. Dysrhythmias are not related to total parenteral nutrition, but may be a sign of hyperkalemia or hypokalemia.
In a health care unit, there are 30 clients and the charge nurse delegates the healthcare team for providing client care. Which statements made by the delegator would indicate care responsibilities are assigned to unlicensed assistive personnel (UAP)? Select all that apply "Note the oxygen saturation reading." "Administer oral antibiotic medications." "Check whether the client is taking fluids." "Admit the client to the intensive care unit." "Ensure that the client has time for uninterrupted sleep."
Unlicensed assistive professionals are delegated to perform tasks such as collecting data that will be used to assess the client. Noting the oxygen saturation readings is a role of the UAP, as is checking the basic needs of the client such as the intake of fluids. The delegator would also assign ensuring whether the client is provided sufficient time to sleep without interruptions to the UAP. Administration of oral antibiotic medications should be delegated to the licensed nursing professionals but not to UAP. Admitting the client to intensive care unit is a task that should be delegated to the licensed nursing professionals.
A nurse caring for a client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which activities should the nurse perform to meet the client's safety and security needs? Select all that apply. Providing a cold bath to reduce the client's body temperature Positioning the bed in a low position and keeping the side rails up Monitoring vital signs, such as blood pressure to decrease the risk of falls Observing a client who has suicidal tendencies to prevent adverse incidents Collaborating with family members to provide emotional support for the client post-surgery nt's love and belonging needs.
Rationale As per Maslow's hierarchy of needs, to meet the safety and security needs of the client, the nurse should position the bed in a low position and keep the side rails up to provide physical safety for the client. Monitoring vital signs, including blood pressure to prevent risk for falls is an example of a nursing activity that meets the client's safety and security needs. Observing a client who has suicidal tendencies to prevent adverse incidents is an example of a nursing activity that meets the client's safety and security needs. Providing a cold bath to the client to reduce body temperature is an example of a nursing activity that meets the client's physiological needs. Collaborating with family members to provide emotional support to the client post-surgery is an example of a nursing activity that meets the clie
Which functions are registered nurses legally permitted to perform in a mental health hospital? Select all that apply. Psychotherapy Health promotion Case management Prescribing medication Treating human responses
Rationale Health promotion, case management, and treating human responses are all within the legal scope of nursing practice. Registered nurses may use counseling interventions but may not perform psychotherapy; the members of the nursing team permitted to perform psychotherapy are psychiatric/mental health clinical nurse specialists and psychiatric/mental health nurse practitioners. Only those who are legally licensed to prescribe medications, such as psychiatric nurse practitioners, may do so.
A nursing student is listing the characteristics of an ethical issue. Which point listed by the nursing student requires correction? An ethical issue occurs if it is perplexing and if it is not easy to think logically or make a decision. An ethical issue occurs if it is not possible to resolve solely through a review of scientific data. An ethical issue occurs if the problem aims at the greatest good for the greatest number of people. An ethical issue occurs if the answer to the problem has a profound relevance for areas of human concern.
Rationale The utilitarianism system of ethics decides on the right action based on the greatest good for the greatest number of people. This is not a characteristic feature of an ethical dilemma. A situation can be called an ethical dilemma if it fulfills one of three conditions. An ethical issue is challenging and generally cannot be solved through logical decision-making. An ethical issue cannot be solved solely through a review of scientific data. If the answer to a specific problem has a profound relevance for areas of human concern, then it is an ethical issue.
A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? Become aware of their personal values Gain information related to their needs Make correct decisions related to their health Alter their value systems to make them more socially acceptable
Rationale Value clarification is a technique that reveals individuals' values so the individuals become more aware of them and their effect on others. Gaining information, making correct health decisions, and altering value systems to make them more socially acceptable are not outcomes of value clarification.
A nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods should the nurse include in the teaching? Select all that apply. Carrots Oranges Tomatoes Green leafy greens Yellow/orange vegetables
Rationale Yellow/orange vegetables, like carrots, contain large quantities of vitamin A in human nutrition. Cantaloupe, sweet potatoes, and apricots also are high in vitamin A. Dark-green leafy vegetables contain large quantities of vitamin A in human nutrition. Oranges are considered a good source of both vitamin C and potassium. Tomatoes are a good source of vitamin C.