Med Surge exam #4 Leadership

delegation

"duties." • scope of practice • 1- Rules and regulations of your state's BON • 2- Interpretations, guidelines, and memorandums developed by your state's board of nursing regarding delegation • Transferring the authority to perform nursing duties that are in the job description of the LP/LV charge nurse • May refuse • LPN responsible for anything they delegate! specific time frames given - Entrusting the performance of a selected nursing task to an individual who is qualified, competent, and able to perform such tasks. The nurse retains accountability for the total nursing care of the individual.

assignment

"tasks." allotting tasks that are in the job description of these health care workers. • LP/LV charge nurse needs to monitor the performance of the task and evaluate the quality and effectiveness of the care • Cannot refuse • NA job responsibility the way that work is distributed among team members for the shift. Assigning is a skill that every LPN/LVN needs to develop if their state allows them to assume a charge nurse position

Avoid potential environmental asthma triggers such as smoke Use the inhaler 30 minutes before exercising to prevent bronchospasm Be sure to get at least 8 hours of rest and sleep every night Avoid foods prepared with monosodium glutamate (MSG) (Rationale: Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma)

17. Question You are providing care for a patient with recently diagnosed asthma. Which key points would you be sure to include in your teaching plan for this patient? Select all that apply. A. Avoid potential environmental asthma triggers such as smoke. B. Use the inhaler 30 minutes before exercising to prevent bronchospasm. C. Wash all bedding in cold water to reduce and destroy dust mites. D. Be sure to get at least 8 hours of rest and sleep every night. E. Avoid foods prepared with monosodium glutamate (MSG).

Perform postural drainage and chest physiotherapy every 4 hours (Rationale: Option A: Airway clearance techniques are critical for patients with cystic fibrosis and should take priority over other activities. Option B: Although allowing more independent decision making is important for adolescents, the physiologic need for an improved respiratory function takes precedence at this time. Option C: A private room may be desirable for the patient but is not necessary. Option D: With increased shortness of breath, it will be more important that the patient has frequent respiratory treatments than 8 hours of sleep)

A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient's care? A. Perform postural drainage and chest physiotherapy every 4 hours. B. Allow the patient to decide whether she needs aerosolized medications. C. Place the patient in a private room to decrease the risk of further infection. D. Plan activities to allow at least 8 hours of uninterrupted sleep.

Stock the client's room with the required PPE items. Reminding the visitors to wear a face mask, gloves, and gown. Posting the precautions for protective isolation on the door of the client's room (Rationale: Options C, D, and E: Delegation. The nursing assistant is capable of stocking the room and posting the precautions on the client's door because all staff who care for clients should be familiar with the various types of isolation. Reminding visitors about previously taught information is a task of the nursing assistant although the RN is responsible for the initial teaching. Options A and B: Client education and discussion of the reason for the protective isolation fall within the RN-level-scope of practice)

A 7-year-old girl who has just endured allogeneic stem cell transplantation will need protective environmental stimulation. Which nursing task should the nurse delegate to the nursing assistant? Select all that apply. A. Educating the client to perform careful handwashing after using the bathroom. B. Communicating with the family members about the grounds for isolation. C. Stock the client's room with the required PPE items. D. Reminding the visitors to wear a face mask, gloves, and gown. E. Posting the precautions for protective isolation on the door of the client's room

Administer oxygen via nasal cannula (Rationale: The promotion of adequate oxygenation is the most vital to life and therefore should be given the highest priority by the nurse)

A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the following assessment cues: pale, diaphoretic, blood pressure of 90/60, respirations of 33. The client is also anxious and fearing death. Which action should the nurse take first? A. Administer pain medications B. Administer IV fluids C. Administer dopamine D. Administer oxygen via nasal cannula

A deviated trachea (Rationale: Option C: A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory arrest if not managed. Options A, B, and D: The remaining options are of lower priority but still need to be addressed)

A client with multiple injuries is rushed to the ED after a head-on car collision. Which assessment finding takes priority? A. Irregular apical pulse B. Ecchymosis in the flank area C. A deviated trachea D. Unequal pupils

He pulled the stick out because it was too painful for him (Rationale: Option C: An impaled object may be giving a tamponade effect, and removal can result in abrupt hemodynamic decompensation. Options A and B: Information such as the dirt on the stick or history of diabetes, is significant in the overall treatment plan but can be addressed next. Option D: Additional history including a more precise extent of blood loss, depth of penetration, and medical history should be collected)

A high school student comes in the triage area alert and ambulatory, and his uniform is soaked with blood. He and his classmates are sounding, "We were running around outside the school and he got hit in the abdomen with a stick!" Which statement should be a priority? A. "The stick was absolutely filthy and muddy." B. "He has a family history of diabetes, so he requires attention right now." C. "He pulled the stick out because it was too painful for him." D. "There was plenty of blood so we used three gauzes."

Democratic

A mixture of focusing on tasks and employees. Useful in daily nursing care, unit meetings, and reviews of patient care plans. Goals may take longer than autocratic leadership but are usually accomplished with employee satisfaction

Determine the level of consciousness (Rationale: Assessing the level of consciousness should be the first action when dealing with clients that might have fallen over)

A nurse enters a room and finds a patient lying face down on the floor and bleeding from a gash in the head. Which action should the nurse perform first? A. Determine the level of consciousness B. Push the call button for help C. Turn the client face up to assess D. Go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician

I will only medicate you every 4 hours

A nurse is caring for a patient who is experiencing excruciating pain and requires frequent administration of analgesics. What statement would be an example of the nurse demonstrating aggressive communication? a. Please let me know when you start to have pain. b. Lets practice some guided imagery. c. Lets try repositioning you. d. I will only medicate you every 4 hours.

risk for aspiration (rationale: ABC)

A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which nursing diagnosis is the highest priority for this client? (priority question: what would kill the pt first?) a. diarrhea b. risk for aspiration c. risk for deficient fluid volume d. imbalance nutrition, less than body requirements

a client on 24 hour urine collection who is on strict bedrest

A nurse manager is planning the client assignments for the day. Which of the following clients would the nurse assign to the nursing assistant? a. a 12-hour postoperative client who has a below the knee amputation b. a client on a 24-hour urine collection who is on strict bed rest c. a client scheduled to be discharged after coronary artery bypass surgery d. a client scheduled for a cardiac catheterization

investigate the situation further

A patient is getting improper care how would you as the nurse handle that?

Use a lift sheet when moving and positioning the patient in bed Use an electric razor when shaving the patient each day Use a soft-bristled toothbrush or tooth sponge for oral care Be sure the patient's footwear has a firm sole when the patient ambulates

A patient with a pulmonary embolism is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply. A. Use a lift sheet when moving and positioning the patient in bed. B. Use an electric razor when shaving the patient each day. C. Use a soft-bristled toothbrush or tooth sponge for oral care. D. Use a rectal thermometer to obtain a more accurate body temperature. E. Be sure the patient's footwear has a firm sole when the patient ambulates.

Perform endotracheal intubation and initiate mechanical ventilation

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a non-rebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action? A. Perform endotracheal intubation and initiate mechanical ventilation. B. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth. C. Administer furosemide (Lasix) 100 mg IV push stat. D. Call a code for respiratory arrest

Assisting the patient to sit up on the side of the bed (Rationale: Option A: Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of a nursing assistant. Options B, C, and D: Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate for a licensed nurse)

A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant? A. Assisting the patient to sit up on the side of the bed. B. Instructing the patient to cough effectively. C. Teaching the patient to use incentive spirometry. D. Auscultation of breath sounds every 4 hours

Remind the patient to sleep on his side instead of his back (Rationale: Option C: The nursing assistant can remind patients about actions that have already been taught by the nurse and are part of the patient's plan of care. Options A, B, and D: Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can delegate the administration of medication to an LPN/LVN)

A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant? A. Discuss weight-loss strategies such as diet and exercise with the patient. B. Teach the patient how to set up the BiPAP machine before sleeping. C. Remind the patient to sleep on his side instead of his back. D. Administer modafinil (Provigil) to promote daytime wakefulness.

the nurse, without consent, touched the patient in an offensive, insulting, or injurious way battery

A student nurse is studying assault and battery. The student interprets assault and battery to include A. the nurse, without consent, touched the patient in an offensive, insulting, or injurious way. B. the nurse threatened to put the patient in restraints if they did not stay in bed. C. the nurse said the bill has to be paid before the patient can leave. D. the nurse failed to perform an act expected of a reasonable nurse.

covalense

Acute symptoms disappear and total recovery could take days to months

A 50-year old with asthma who complains of shortness of breath after using a bronchodilator (Rationale: Option D: The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. Options A, B, and C: The other patients need to be assessed as soon as possible, but none of their situations are urgent. In COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable)

After a change of shift, you are assigned to care for the following patients. Which patient should you assess first? A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab. B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation. C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics. D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator.

An abandoned person who is a teacher; has altered mental state, weak muscle movement, hot, dry, pale skin; and whose duration of heat exposure is unknown. An elderly traffic enforcer who complains of dizziness and syncope after standing under the heat of the sun for several hours to perform his job. A sportsman who complains of severe leg cramps and nausea, and displays paleness, tachycardia, weakness, and diaphoresis. A comparatively healthy housewife who states that the air conditioner has been down for 5 days and who exhibits hypotension, tachypnea, profuse diaphoresis, and fatigue.

After exposure to hot weather and sun, clients with signs and symptoms of heat-related ailment rush to the Emergency Department (ED). Sort clients into those who need critical attention and those with less serious conditions. An abandoned person who is a teacher; has altered mental state, weak muscle movement, hot, dry, pale skin; and whose duration of heat exposure is unknown. An elderly traffic enforcer who complains of dizziness and syncope after standing under the heat of the sun for several hours to perform his job. A sportsman who complains of severe leg cramps and nausea, and displays paleness, tachycardia, weakness, and diaphoresis. A comparatively healthy housewife who states that the air conditioner has been down for 5 days and who exhibits hypotension, tachypnea, profuse diaphoresis, and fatigue.

Tympanic temperature of 101.4ºF (38.6ºC) (Rationale: Infections are always a threat to the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the respiratory system)

After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the registered nurse immediately? A. Heart rate of 98 beats/min B. Respiratory rate of 24 breaths/min C. Blood pressure of 168/90 mm Hg D. Tympanic temperature of 101.4ºF (38.6ºC)

48 year old patient with shortness of breath, respirations, and pulse ox 88% (Rationale: ABCs or expected and non-expected)

An LPN has just finished receiving report on from the previous shift. Which client should the nurse assess first? a. 48-year-old patient with shortness of breath, respirations and pulse ox of 88% b. a 52 year old patient with with a WBC of 22 c. A 59 year old patient with chest pain increases with deep expiration d. An 89 year old with a UTI who is confused

he or she must review the state's nurse practice act for LPN/LVNs because each state defines the role and scope of practice of the LPN/LVN (Rationale: Nurse practice acts define delegation)

An LPN recently relocated to another region of the country and immediately assumed the role of charge nurse. When determining the appropriate person to whom to delegate, the RN knows that: a. the role of the LPN/LVN is the same from state to state b. the LPN/LVN can be taught to perform all the duties of an RN if approved by the employer and if additional on the job training is provided c. he or she must review the state's nurse practice act for LPN/LVNs because each state defines the role and scope of practice of the LPN/LVN d. The Joint Commission has certified and established roles for the LPN/LVN

Auscultate breath sounds Administer medications via metered-dose inhaler (MDI) (Rationale: Options A and B: The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN. Options C, D, and E: Independently completing the admission assessment, initiating the nursing care plan, and evaluating a patient's abilities require additional education and skills. These actions are within the scope of practice of the professional RN)

An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply. A. Auscultate breath sounds B. Administer medications via metered-dose inhaler (MDI) C. Complete in-depth admission assessment D. Initiate the nursing care plan E. Evaluate the patient's technique for using MDI's

objective data

Data the nurse obtains through their assessment and observation vial signs; a physical assessment

negligence

Doing something a normally prudent nurse would not do; done unintentionally conduct that falls below the standards

assault and battery

Forcing a client to take medication or treatment can result in what type of charge for the nurse?

communication/direction responsibilities of the Licensed Practical/Licensed Vocational charge nurse when assigning or delegating

Give objective, detailed, clear-cut verbal and written directions. Get to the points Consider writing assignments in a concise, objective manner on a master assignment sheet Clarify if the nursing assistant has performed delegated duty in the past Explain what is expected at the nursing assistant's level of understanding Be specific about the results you are expecting and when to report. Do not ask nursing assistants to "find out how patient is" Instead, ask a patient who has been itching because of a rash if the rash still itches Provide guidelines for reporting after the delegated duty is completed. Provide the time you expect to be informed and why Make sure your directions are specific and complete. Provide all necessary information, including time, to get the task or duty done correctly or safely. For example, say, "Please report the numbers immediately after you message Mr. Smith's blood pressure, pulse, and respirations. I need to know the numbers before his 9:00 A.M. blood pressure medicine can be given Given specific directions, nursing assistants can collect, report and document simple data. However, they are unable to make judgements based on those data. For example, say, "Please report the results of Mr. Ettie's finger stick immediately after you perform it so I can determine if he needs insulin" Instruct nursing assistants when to consult with the charge nursing during the performance of an assigned/delegated duty. For example, say, " Let me know immediately if you are having trouble getting the specimen" Clarify all messages by asking nursing assistants to tell you what it is you expect them to do and when to report A "please" and "thank you" are in order as part of common courtesy

negative feedback

Identifies behaviors that need improvement provide verbal feedback as close to the event as possible, focus on the behavior as one needing improvement. Avoid addressing the behavior as criticism. Without emotion, objectively point out what is wrong with the behavior and its consequences. accompanied by suggestions to correct the behavior. Specific . mention behaviors that need improvement first. Offer praise at the end of a reprimand. Give with "I" statement

positive feedback

Identifies strong behaviors to be encouraged Catch them doing something "RIGHT" (This encourages them to repeat the behavior) Let nursing assistants know you notice their effects, believe in them, and feel good about their contributions to the facility. Praise people in measurable terms (specific and objective) so that behavior can be repeated. For example, say, "When you disinfected the shower, I noticed that you paid special attention to the corners and the shower chair. Great Job!"

droplet precautions

In addition to standard precautions, the nurse caring for a patient with rubella would plan to implement what type of precautions? a. Droplet precautions b. Airborne precautions c. Contact precautions d. Universal precautions

Prioritization

In test questions that ask the nurse which action to take first, two or more of the options will be appropriate nursing interventions for the situation described. When choosing the correct answer, the test taker must decide which intervention should occur first in a sequence of events, or which intervention directly impacts the situation. With a question that asks which client should the nurse assess first, the test taker should first look at each option and determine if the signs/symptoms the client is exhibiting are normal or expected for the disease process; if so, the nurse does not need to assess that particular client first. Second, if two or more of the options state signs/symptoms that are not normal or expected for the disease process, then the test taker should select the option that has the greatest potential for a poor outcome. Each option should be examined carefully to determine the priority by asking these questions: • Is the situation life threatening or life altering? If yes, this client is the highest priority. • Is the situation unexpected for the disease process? If yes, then this client may be priority. • Is the data presented abnormal? If yes, then this client may be priority. • Is the situation expected for the disease process and not life threatening? If yes, then this client may be—but probably is not—priority. • Is the situation/data normal? If yes, this client can be seen last. The test taker should try to make a decision pertaining to each option.

Remove gloves Take off gown Take off goggles Remove N95 respirator Perform hand hygiene

In which order will the nurse perform the following actions as she prepares to leave the room of a client with airborne precautions after performing oral suctioning? Remove gloves Take off gown Take off goggles Perform hand hygiene Remove N95 respirator

A client who had a total hip replacement two days ago and needs blood glucose monitoring (Rationale: A nurse from the medical-surgical floor floated to the orthopedic unit should be given clients with a stable condition as those who have care similar to her training and experience. A client who is in a postoperative state is more likely to be in a stable condition)

Jenna is a nurse from the medical-surgical unit of a tertiary hospital. She was asked to float on the orthopedic in which she has no prior experience working on. Which client should be assigned to her? A. A client with a cast for a fractured femur and who has numbness and discoloration of the toes. B. A client with balanced skeletal traction and needs assistance with morning care. C. A client who had an above-the-knee amputation yesterday and currently has a temperature of 101.4ºF. D. A client who had a total hip replacement two days ago and needs blood glucose monitoring.

Situational

Leadership style varies to meet situation

Contact the nursing supervisor to address the situation (Rationale: The nurse should use a proper channel of communication. The nursing supervisor is responsible for the actions of the different members of the nursing team)

Nurse Adonai is working on the night shift with a nursing assistant. The nursing assistant comes to the nurse stating that the other nurse working on the unit is not assessing a client with abdominal pain despite multiple requests. Which of the following actions by the nurse is best? A. Ask the other nurse if she needs help B. Assess the client and let the other nurse know what should be done C. Ask the client if he is satisfied with his care D. Contact the nursing supervisor to address the situation

A 35-year-old male with tracheostomy and copious secretions (Rationale: The patient with an airway problem should be given the highest priority. Remember Airway, Breathing, and Circulation (ABC) is a priority)

Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first? A. A client with diabetes being discharged today. B. A 35-year-old male with tracheostomy and copious secretions. C. A teenager scheduled for physical therapy this morning. D. A 78-year-old female client with a pressure ulcer that needs dressing change.

broccoli (Rationale: Broccoli is known to be gas-forming which can lead to bloating and therefore, should be avoided)

Nurse Jackie is reviewing the diet of a 28-year-old female who reports several months of intermittent abdominal pain, abdominal bloating, and flatulence. The nurse should tell the client to avoid: A. Fiber B. Broccoli C. Yogurt D. Simple carbohydrates

Establish whether the client is responsive (Rationale: Assess the client's current level of consciousness first to determine whether the patient has had a loss of consciousness then do the remaining choices if possible)

Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first? A. Call for help to get the client back in bed B. Establish whether the client is responsive C. Assist the client back to bed D. Ask the client what happened

Wound infection (Rationale: Wound infection is the most common complication among obese clients who had undergone surgery. This is due to their poor blood supply in their adipose tissues)

Nurse Paul is developing a care plan for a client after bariatric surgery for morbid obesity. The nurse should include which of the following on the care plan as the priority complication to prevent: A. Pain B. Wound infection C. Depression D. Thrombophlebitis

A client with chronic bronchitis on nasal oxygen (Rationale: A client with airway problems should be attended first)

Nurse Skye is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first? A. A client scheduled for cardiac ultrasound this morning. B. A client with syncope being discharged today. C. A client with chronic bronchitis on nasal oxygen. D. A client with diabetic foot ulcer that needs a dressing change

Pneumococcal vaccine (Rationale: Pneumococcal vaccine is a priority immunization amongst the elderly, especially those with chronic illnesses. It is administered every five (5) years)

Nurse Vivian is reviewing immunizations with the caregiver of a 72-year-old client with a history of cerebrovascular disease. The caregiver learns which immunization is a priority for the client? A. Hepatitis A vaccine B. Lyme's disease vaccine C. Hepatitis B vaccine D. Pneumococcal vaccine

Lack of trust in the members of the healthcare team (Rationale: Lack of trust is the common reason for reluctance in a delegation of tasks. Lack of trust is the common reason for reluctance in delegation of tasks)

Paige is a nurse preceptor who is working with a new nurse, Joyce. She notes that Joyce is reluctant to delegate tasks to members of the care team. Paige recognizes that this reluctance is most likely due to: A. Role modeling behaviors of the preceptor B. The philosophy of the new nurse's school of nursing C. The orientation provided to the new nurse D. Lack of trust in the members of the healthcare team

Laissez-Faire

People-oriented focuses on people but ignores tasks. Responsibility is solely placed on employees. People pleasers. Does not embody organizational goals or policies. Best when policy is not a consideration

patient will maintain FSBG b/w 90-110 ACHS throughout hospitalization

Provide a good example of a plan for a hospitalized diabetic

duty

Refers to the nurse's responsibility to provide care in an acceptable way.

Decontaminate the open wound on the client's thigh (Rationale: Decontaminating an open wound is the first priority for the client. This minimizes the absorption of radiation in the client's body)

Sally is a nurse working in an emergency department and receives a client after a radiological accident. Which task is the utmost priority for the nurse to do first? A. Decontaminate the client's clothing. B. Decontaminate the open wound on the client's thigh. C. Decontaminate the examination room the client is placed in. D. Save the client's vomitus for analysis by the radiation safety staff.

Maslow's Heirarchy of Human Needs

Self- actualization = hope, spiritual well-being , enhanced growth self-esteem= control, competence, positive regard, acceptance/worthiness Love & well-being= maintain support systems, protect from isolation Safety & Security= protect from injury, promote feeling of security, trust in nurse-client relationship Physiological needs= airway, respiratory effort, heart rate, rhythm, and strength of contraction, nutrition elimination (these are your priority pt's)

A 68-year-old man with a pulsating abdominal mass and sudden onset of "tearing" pain in the abdomen and flank within the past hour A 38-year-old man complaining of severe occasional cramps with three episodes of watery diarrhea hours after meal

Several clients arrive in the ED with the same complaint of abdominal pain. Designate them for care in order of the severity of their condition. A 53-year-old man who experiences discomforting mid-epigastric pain that is worse between meals and during the night. A 25-year-old woman complaining of dizziness and severe left lower quadrant pain who states she is probably pregnant. A 68-year-old man with a pulsating abdominal mass and sudden onset of "tearing" pain in the abdomen and flank within the past hour. A 38-year-old man complaining of severe occasional cramps with three episodes of watery diarrhea hours after meal. A 12-year-old girl with a low-grade fever, anorexia, nausea, and right lower quadrant tenderness for the past 2 days. A 42-year-old woman with moderate right upper quadrant pain who has vomited little amounts of yellow bile and whose symptoms have worsened over the past week.

An individual who was injured and trapped for 8 hours before rescue (Rationale: Any of these victims may need or require psychiatric counseling. There will be changes in previous coping skills and support groups; nevertheless, the individual who encountered a threat to his or her own life is at the greatest chance of having psychiatric difficulties following a disaster incident)

Several people were killed and injured in a recent industrial explosion. The victims are being interviewed and assessed by the nurses for possible psychiatric crises. Which client has the greatest risk for posttraumatic distress disorder? A. An individual who was injured and trapped for 8 hours before rescue. B. A person who saw the death of a co-worker during the blast. C. An individual who recently discovered that her daughter was killed in the incident. D. A person who repeatedly watched television coverage of the event.

illness stage

Symptoms specific to the infection appear i.e. sore throat

truth ( is it true?) useful (is what you are going to tell me useful) good method (is what you are going to say good?)

TUG: abbreviation for nurse bullying

Autocratic

Task- centered, thrives on power, little regard to employees satisfaction, emphasis on policies, does not allow input from subordinates, best used is crisis, code, and emergency situations

Performing chest compressions (Rationale: Option B: Basic cardiac life support is learned by nursing assistants so they can perform chest compressions. Option A: The nurse or the respiratory therapist should provide assistance as needed during intubation. Option C: The defibrillator pads are accurately labeled; nevertheless, the responsibility of placing them should be done by the RN or physician because of the potential for skin damage and electrical arcing. Option D: The use of the bag valve mask demands practice, and normally, a respiratory therapist will implement this measure)

The ambulance has transported a man with severe chest pain. As the man is being transferred to the emergency stretcher, the nurse assessed the following: unresponsiveness, cessation of breathing, and absence of palpable pulse. Which of the following tasks is proper to assign to the nursing assistant? A. Aiding with oral intubation B. Performing chest compressions C. Placing the defibrillator pads D. Starting bag valve mask ventilation

A 72-year old who needs teaching about the use of incentive spirometry (Rationale: Option C: Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. Option A: To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. Options B and D: The bronchoscopy patient needs specialized procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses)

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit? A. A 58-year old on airborne precautions for tuberculosis (TB). B. A 68-year old just returned from bronchoscopy and biopsy. C. A 72-year old who needs teaching about the use of incentive spirometry. D. A 69-year old with COPD who is ventilator dependent

insert an 18 gauge catheter and infuse lactated ringer's (rationale: 1. Notifying the laboratory for a type & crossmatch would be an appropriate intervention since the client is showing signs of hypovolemia, but it is not the first intervention because it would not directly support the client's circulatory volume. 2. The stem of the question has provided enough assessment data to indicate the client's problem of hypovolemia. Further assessment data are not needed. 3. The vital signs indicate hypovolemia, which is a life-threatening emergency that requires the nurse to intervene to support the client's circulatory volume. The nurse can do this by infusing lactated Ringer's. 4. A pulse oximeter reading would not support the client's circulatory volume)

The client diagnosed with peptic ulcer disease has a blood pressure of 88/42, an apical pulse of 132, and respirations are 28. The nurse writes the nursing diagnosis "altered tissue perfusion related to decreased circulatory volume. " Which intervention should the nurse implement first? 1. notify the laboratory to draw a type & crossmatch 2. assess the client's abdomen for tenderness 3. insert an 18-gauge catheter and infuse lactated Ringer's 4. check the client's pulse oximeter reading (the nursing process)

Give sodium polystyrene sulfonate (Kayexalate) 15 g orally (Rationale: Option B: Delegation, supervision. The normal range for potassium is 3.5 to 5 mEq/L. The client's potassium level is high. Kayexalate eliminates potassium from the body through the gastrointestinal system. Option A: Giving additional potassium may further increase the serum potassium level. Option C: Spironolactone is a potassium-sparing diuretic that may cause the client's potassium level to go even higher. Option D: The beginning nursing student does not have the skill to assess ECG strips)

The clinical instructor directed the student nurse to care for a client whose potassium is 6.7 mEq/L. Which intervention is delegated correctly to the student nurse? A. Give potassium 10 mEq orally B. Give sodium polystyrene sulfonate (Kayexalate) 15 g orally C. Give spironolactone (Aldactone) 25 mg orally D. Assess the electrocardiogram (ECG) strip for tall T waves

The less experienced nurse could care for the client on a ventilator and console the family as needed. This client is not in a life-threatening situation and is stable for the condition (rationale : The less experienced nurse could care for the client on a ventilator and console the family as needed. This client is not in a life-threatening situation and is stable for the condition) (2. A client with increased intracranial pressure requires a more experienced critical care nurse. 3. This client is unstable and requires a more experienced critical care nurse. 4. Status epilepticus is a state of continuous seizure activity and is the most serious complication of epilepsy. This is a neurological emergency. This client should be assigned to a more experienced nurse)

The critical care charge nurse is making client assignments for the shift. Which client should the charge nurse assign to the graduate nurse who just completed the orientation? 1. The client with amyotrophic lateral sclerosis on a ventilator who is dying and whose family is at the bedside. 2. The client who has a closed head injury and has increasing intracranial pressure receiving intravenous osmitrol (Mannitol). 3. The client with a C -5 spinal cord injury who is experiencing spinal shock and is on the vasoconstrictor dopamine. 4. The client with a seizure disorder who has been experiencing status epilepticus for the past 24 hours.

Manually ventilate the patient while assessing possible reasons for the high-pressure alarm (Rationale: Option B: Manual ventilation of the patient will allow you to deliver a FiO2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. Options A, C, and D: The patient may need reassurance, suctioning, and/or insertion of an oral airway, but the first step should be an assessment of the reason for the high-pressure alarm and resolution of the hypoxemia)

The high-pressure alarm on a patient's ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next? A. Reassure the patient that the ventilator will do the work of breathing for him. B. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. C. Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning. D. Insert an oral airway to prevent the patient from biting on the endotracheal tube.

incubation stage

The interval between the pathogen entering the body & the presentation of the first symptom (stages of infection)

Place the client on airborne and contact precautions (Rationale: Option A: Prioritization. SARS is considered deadly so the initial action is to protect other clients and healthcare workers by securing the client in isolation. If an airborne-agent isolation (negative-pressure) room is not yet available, droplet precautions should be initiated until the client can be moved to a negative-pressure room. Options B, C, and D: The other actions should also be taken immediately but are not as important as preventing transmission of the disease)

The nurse assessed the client and noted shortness of breath and a recent trip to China. The client is strongly suspected of having Severe Acute Respiratory Syndrome (SARS). Which of these prescribed actions will the nurse take first? A. Place the client on airborne and contact precautions B. Introduce normal saline at 75 mL/hr C. Give methylprednisolone (SOLU-Medrol) 1 g intravenously (IV) D. Take blood, urine, sputum cultures

The UAP will be practicing on my brand new nursing license (rationale: An LPN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to a UAP. Tasks that cannot be delegated are nursing interventions requiring nursing judgment. The nurse must be aware of delegation rules and regulations. 1. This statement indicates the new graduate needs more teaching because the nurse is responsible for delegating the right task to the right individual. Absolutely no one works on the nurse's license but the nurse holding the license. 2. The nurse does retain accountability for the task delegated; therefore, the new graduate does not need more teaching. 3. The nurse must make sure the unlicensed assistive personnel (UAP) is able to perform the task safely and competently; therefore, the new graduate does not need more teaching. 4. The nurse must make sure the delegated task was completed correctly; therefore, the new graduate does not need more teaching. Although each state and province has its own Nursing Practice Acts, there are some general guidelines that apply to all professional nurses. • When delegating to an unlicensed assistive personnel (UAP), the nurse may not delegate any activity that requires nursing judgment. These include assessing, teaching, evaluating, or administering medications to any client and the care of any unstable client. • When assigning care to an LPN, the RN can assign the administration of some medications but cannot assign assessing, teaching, or evaluating any client and cannot delegate the care of an unstable client)

The nurse educator on a vascular unit is discussing delegation guidelines to a group of new graduates. Which statement from the group indicates the need for more teaching? 1. "The UAP will be practicing on my brand new nursing license." 2. "I will still retain accountability for what I delegate to the UAP." 3. "I must make sure the UAP to whom I delegate is competent to perform the task." 4. "When I delegate, I must follow up with the UAP and evaluate the task." (delegation question)

The client on strict bed rest who is complaining of calf pain and has a reddened calf (rationale: 1. Intermittent claudication is a symptom of arterial occlusive disease; therefore, this client does not need to be assessed first. 2. The client with calf pain could be experiencing deep vein thrombosis (DVT), a complication of immobility, which may be fatal if a pulmonary embolus occurs; therefore, this client should be assessed first. 3. The client experiencing low back pain when sitting in a chair should be assessed but not prior to the client with suspected DVT. 4. The nurse should address the client's concern about the food, but it is not priority over a physiological problem) (The nurse is frequently called upon to make decisions about staffing, movement of clients from one unit to another, or handling conflicts as they arise. Some general guidelines for answering questions in this area include the following: • The most experienced nurse gets the most critical client. • A graduate nurse can take care of any client who is receiving care from a student with supervision. • The most stable client can move or be discharged; whereas, the most unstable client must move to intensive care unit (ICU) or stay in ICU. When the nurse must make a decision regarding a conflict in the nursing station, a good rule to follow is to use the chain of command. The primary nurse should confront a peer (another primary nurse) or a subordinate unless the situation is illegal (such as stealing drugs). The primary nurse should use the chain of command in situations that address superiors (a manager or director of nursing); then the nurse should discuss the situation with the next in command above the superior)

The nurse has finished receiving the morning change-of-shift report. Which client should the nurse assess first? 1. The client diagnosed with arterial occlusive disease who has intermittent claudication. 2. The client on strict bed rest who is complaining of calf pain and has a reddened calf. 3. The client who complains of low back pain when lying supine in the bed. 4. The client who is upset because the food doesn't taste good and is cold all the time (management question)

Gloves Gown

The nurse is assigned to a client who has a draining sacral wound infected by MRSA. Which personal protective equipment (PPE) will the nurse plan to use in preparing to change the linens of the client? Select all that apply. A. Gloves B. Goggles C. Gown D. N95 respirator E. Surgical mask F. Shoe covers

check the client for adventitious lung sounds (rationale: check for adventitious lung sounds is assessing the client to determine the extent of the client's breathing difficulties causing the dyspnea)

The nurse is caring for a client diagnosed with congestive heart failure who is currently complaining of dyspnea. Which intervention should the nurse implement first? 1. administer furosemide (Lasix), a loop diuretic, IVP 2. check the client for adventitious lung sounds 3. ask the respiratory therapist to administer treatment 4. notify the healthcare provider (The nursing process: when you see the word "first" indicates priority)

Measure vital signs every 15 minutes (Rationale: Options C and D: Delegation, supervision. A well-trained and educated nursing assistant is knowledgeable in measuring vital signs and recording intake and output. Options A and B: Performing fingerstick glucose checks and assessing clients demands further education and skill, as possessed by licensed nurses)

The nurse is caring for a client diagnosed with diabetic ketoacidosis. Which action should you delegate to the nursing assistant? Select all that apply. A. Assess for indicators of fluid imbalance. B. Review finger stick glucose results every hour. C. Measure vital signs every 15 minutes. D. Document intake and output every hour.

ensure tracheal suction catheters are present at the patient's bedside (safety; ABC; Maslow's)

The nurse is planning care for a 68 year old patient who underwent mandibular resection and tracheostomy two hours ago for throat cancer that had metastasized to his jaw. Which intervention is most important for this patient? a. Administer scheduled intravenous pain medication as ordered b. Place sequential compression devices (SCDs) on the patient's legs c. Arrange a meeting with a tracheostomy support group representative d. ensure tracheal suction catheters are present at the patient's bedside

Autocratic

The nurse manager for the emergency department (ED) is preparing the staff for the arrival of multiple trauma patients. Which type of leadership will the nurse manager implement? a. Laissez-faire b. Autocratic c. Democratic d. Bureaucratic

3, 1, 4, 2, 5 (rationale: 3. This client may be chilling, indicting a potential rise in temperature. The nurse should assess the client and the temperature to see if interventions should be initiated based on a progression of the septicemia. 1. This client should be assessed to be sure that the client is stable because there was chest pain during the last shift. 4. The nurse should assess the client next because although confusion is expected, the nurse must determine whether any new situation is occurring. 2. This client has a psychosocial need but it must be addressed and steps implemented to resolve the problem. 5. A dressing change can take some time to complete. This is a physiological situation but not a life-threatening one and the nurse should see this client when he/she has time to perform the dressing change)

The nurse on a medical unit is making rounds after receiving the shift report. Which client should the nurse see first? Rank in order of priority. 1. The 45-year-old client who complained of having chest pain at midnight last night and received NTG sublingually. 2. The 62-year-old client who is complaining that no one answered the call light for 2 hours yesterday. 3. The 29-year-client diagnosed with septicemia who called to request more blankets because of being cold. 4. The 78-year-old client diagnosed with dementia whose daughter is concerned because the client is more confused today. 5. The 37-year-old client who has a Stage 4 pressure sore and the dressing needs to be changed this morning

respiratory status (Rationale: Assessing respiratory status is the first priority. Remember ABC)

The nurse plans care for a client in the post-anesthesia care unit. Which of the following should the nurse assess first? A. Respiratory status B. Level of consciousness C. Level of pain D. Reflexes and movement of extremities

Suggest that the patient's oxygen be humidified (Rationale: Option A: When the oxygen flow rate is higher than 4 L/min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Options B, C, and D: Application of a water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem)

The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient's comfort for this problem? A. Suggest that the patient's oxygen be humidified. B. Suggest that a simple face mask be used instead of a nasal cannula. C. Suggest that the patient be provided with an extra pillow. D. Suggest that the patient sit up in a chair at the bedside.

management

The organization of all care required of patients in a health care setting for a specific period

assessment

The patient has pitting edema + 3 on the leg. Where does this patient information go in the SBAR?

Observe how well the patient performs pursed-lip breathing (Rationale: Option A: Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Options B and D: Planning and consulting require additional education and skills, appropriate to an RN. Option C: Assisting patients with ADLs is more appropriately delegated to a nursing assistant)

The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision? A. Observe how well the patient performs pursed-lip breathing. B. Plan a nursing care regimen that gradually increases activity intolerance. C. Assist the patient with basic activities of daily living. D. Consult with the physical therapy department about reconditioning exercises.

the registered nurse (RN) (RN completes intitial assessments/teachings)

The task of completing and signing the initial assessment on a newly admitted patient who is about to undergo minimally invasive procedures on an outpatient basis can be delegated to: a. the registered nurse (RN) b. the licensed practical/vocational nurse (LPN/LVN) d. all levels of staff, because the information is about the past and cannot change

Laissez-faire

The unit manager of a 32-bed medical-surgical unit allows the staff nurses to do self-governance for scheduling, client care assignments, and committee work. This sometimes leads to confusion, which the staff must correct. Which type of leader would the nurse manager be considered? a. Bureaucratic b. Autocratic c. Democratic d. Laissez-fair

Surfactant (Exosurf) (Rationale: Option B: Exosurf neonatal is a form of synthetic surfactant. An infant with RDS may be given two to four doses during the first 24 to 48 hours after birth. It improves respiratory status, and research has shown a significant decrease in the incidence of pneumothorax when it is administered. Option A: Theophylline is indicated for the treatment of asthma and COPD (bronchitis, emphysema). Options C and D: Dexamethasone and Albuterol are often used for the treatment of pediatric acute asthma)

To improve respiratory status, which medication should you be prepared to administer to the newborn infant with respiratory distress syndrome (RDS)? A. Theophylline (Theolair, Theochron) B. Surfactant (Exosurf) C. Dexamethasone (Decadron) D. Albuterol (Proventil)

name, phone number, email address, and mailing address

What are some components a resume should contain?

Age (How old are you?) national/origin citizenship (Are you a US citizen?) race/color (All questions regarding race/color) religion ( All questions regarding someone's religious beliefs) marital/family status (Are you married?) personal (How tall are you?, How much do you weigh?) disabilities ( Do you have any disabilities?) arrest record ( Have you ever been arrested?) military (if you were in the military, were you honorably discharged)

What are some things that are illegal to ask during an interview? Select all that apply.

(PACET): Planning Assessment Collaboration Evaluation Teaching IV insertion/ assessment Follow up NEVER initial or first assessment of newly post-op, admitted, or newly dx. NEVER DELEGATE UNSTABLE PATIENTS sterile techniques crisis situations ( you must be there: An example of a crisis situation is a resident who develops chest pain) Initial patient education by the RN( In most states, LPNs/LVNs may reinforce initial patient teaching given by an RN) Although nursing assistants can collect simple data, they have not been trained to make decisions about or interpret those data. (For example, nursing assistants cannot evaluate results of capillary blood glucose monitoring or determine when vital signs need to be rechecked ) Duties that are part of your scope of practice may never be delegated. Your legal scope of practice is your assisting role in the nursing process

What are some things that can not be delegated to the UAP?

V = vaper A = ambulation P = positioning E = eating R = recording NEVER intepret, give medications personal care (hygiene, dressing, toileting, grooming, and skincare) feeding and hydration basic restorative skills: transferring, positioning and ambulation, and maintaining range of motion recording vital signs: height, wt, intake, and output assistance with elimination, including catheter care and enemas maintaining safety factors, including fall prevention, application of heat and cold, and infection prevention collecting specimens or urine and stool nursing assistants who have displayed an excellent work ethic, job performance, and skills may be offered additional, specialized training to become restorative aides additional training occurs for positioning, transferring, performing range of motion, using assistive devices, and preventing pressure ulcers

What are some things you can delegate to the UAP?

The delivery of health care services which are performed under the direction of the professional nurse, licensed physician, or licensed dentist, including observation, intervention, and evaluation, fall within the LPN/LPTN scope of practice

What are tasks in the LPN scope of practice?

right task right circumstance right person right direction/communication right level of supervision

What are the 5 rights of delegation and what is the LPN responsible for when delegating?

1. gown 2. mask/respirator 3. goggles/face shield 4. gloves

What are the steps for donning PPE? (management of care)

1. gown (do together) 2. gloves (do together) 3. mask/respirator 4. wash hands/sanitizer

What are the steps for removing PPE?

A- assessment (gather info review history) D- diagnose (identify problem list i.e. acute paint, risk for infection) P- plan (develop goals, desired outcomes, action plan specific on time frame) I- implement (perform nursing actions) E- evaluate (were desired outcomes and goals achieved?)

What are the steps of the problem-solving process and how do you apply it? ADPIE

measles chickenpox (varicella) disseminated varicella-zoster pulmonary or laryngeal tuberculosis COVID They need a room with negative pressure and cannot pair clients together

What diseases are airborne?

adenovirus diphtheria (pharyngeal) epiglottis influenza (flu) meningitis mumps parvovirus B19 pertussis pneumonia rubella scarlet fever sepsis streptococcal pharyngitis they can be paired together as long as they have the same disorder

What diseases are droplet precautions?

assessment, diagnosis, plan, implementation, evaluation

What does ADPIE stand for?

routine nursing care (i.e. brushing the pt's teeth)

What information would you avoid giving in the SBAR report?

always starts with "patient will" pt will maintain blood glucose of 90 to 110

What is a good care plan "ADPIE" for someone who is a hospitalized diabetic? i.e. goals

philosophy, purpose and goals

What is a mission statement?

mask

What is the PPE steps to take for a patient that has rubella?

online

What is the best way to search for a job?

communication

What is the most important skill in leadership?

A- airway 02 stats, airway clearance/patency B- breathing chest expansion, respiratory rate, position C- circulation perfusion (cyanosis, DVT); blood pressure, pulse Least invasive first = Most invasive last acute versus chronic urgent versus non urgent stable versus non stable must do- HIGHEST PRIORITY OF COMPLETION (examples: tracheostomy suctioning, addressing chest pain) Should Do- NOT CRITICAL, BUT SHOULD BE DONE SOON (examples: wound care, teaching, PRN medications) Nice to Do- DONE AFTER ESSENTIAL TASKS (examples: restocking supplies, hair care)

What is the prioritization in nursing that you would consider?

prioritizing

What needs to be done first

patient's admitting diagnosis date of admission information related to current status, such as recent mental status, vital, oximetry, oxygen device, and flow rate current medication, allergies intravenous (IV) fluids, lab results, code status

What should be included in the Background?Name 3

S. Situation (about 10 seconds). Identify the following about the situation: 1 - Who you are 2. Your unit 3. Patient name and room number 4- What the problem is (briefly), when it started, and how severe it is

What should be included in the Situation of SBAR? Name 3

should be organization-specific and relay the mission, vision, and values

What should the focus of a cover letter be?

send email to the hiring supervisor, thank them for their time after the interview

What should you do for a follow up to an interview?

evidence and documentation

What steps do you take when dealing with employee problems as a charge nurse if it is multiple offense ?

make them figure it out for themselves, don't give your own opinions

What steps do you take when dealing with employee problems as a charge nurse if it is personal problems?

the charge nurse will take each person's point of view and document what is said and make sure objective and go to the next change of command

What steps do you take when dealing with employee problems as a charge nurse if it is the first offense?

subjective data

What the patient tells the nurse I.e. feelings of physical discomfort, anxiety, and mental stress that are more difficult to measure

S situation B background A assessment R recommendation

What things are included in a shift to shift SBAR report?

implementation

What would checking the patient's pulse q 1h fall under in "ADPIE"?

lack of experience

What would you say as a new nurse during an interview that would be your greatest weakness?

I will continue to take my isoniazid until I am feeling completely well (Rationale: Option B: Patients taking isoniazid must continue the drug for 6 months. The other 3 statements are accurate and indicate an understanding of TB. Option A: Family members should be tested because of their repeated exposure to the patient. Option C: Covering the nose and mouth when sneezing or coughing, and placing the tissues in plastic bags help prevent transmission of the causative organism. Option D: The dietary changes are recommended for patients with TB)

When a patient with TB is being prepared for discharge, which statement by the patient indicates the need for further teaching? A. "Everyone in my family needs to go and see the doctor for TB testing." B. "I will continue to take my isoniazid until I am feeling completely well." C. "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag." D. "I will change my diet to include more foods rich in iron, protein, and vitamin C."

Switch the patient to a non rebreather mask at 95% to 100% oxygen and call the physician to discuss the patient's status (Rationale: Option D: The patient's history and symptoms suggest the development of ARDS, which will require intubation and mechanical ventilation. Option A: The maximum oxygen delivery with a nasal cannula is a Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Option B: Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Option C: Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.)

When assessing a 22-year old patient who required emergency surgery and multiple transfusion 3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? A. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. B. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. C. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. D. Switch the patient to a non rebreather mask at 95% to 100% oxygen and call the physician to discuss the patient's status

background

Where does the patient's allergies go in the SBAR?

Auscultating the lungs for crackles (Rationale: Option D: An LPN who has been trained to auscultate lung sounds can gather data by routine assessment and observation, under the supervision of an RN. Options A, B, and C: Independently evaluating patients, assessing for symptoms of respiratory failure, and monitoring and interpreting laboratory values require additional education and skill, appropriate to the scope of practice of the RN)

Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team? A. Evaluating the patient's complaint of chest pain. B. Monitoring laboratory values for changes in oxygenation. C. Assessing for symptoms of respiratory failure. D. Auscultating the lungs for crackles.

I get angry when you are late to work so often and I can't go home. (Rationale: Assertive communication is objective, focuses on behavior, and uses "I" statements. This statement uses an I statement, an objective description of the behavior, and a descriptions of the consequence of the behavior. Asking why someone is so disrespectful is focusing on the person's personal traits and not the problematic behavior. Using "all or nothing" statements or words like "never" and "always" is exaggerating and makes it appear that the person cannot do anything right, which may put him or her on the defensive. Yelling is aggressive, not assertive. Saying "You can't get to work on time" implies that the person is never on time.)

Which of the following is the best example of assertive communication?A. "I am really angry at you because you can't get to work on time." B. "I get angry when you are late to work so often and I can't go home. "C. "Why are you so disrespectful of my time that you are always late? "D. "You are always late and that means I can't go home on time!"

Warfarin (Coumadin) 1.0 mg by mouth (PO) (Rationale: Medication safety guidelines indicate that the use of a trailing zero is not appropriate when writing medication orders because the order can easily be mistaken for a larger dose, such as 10 mg. The order should be clarified before administration. The other orders are appropriate, based on the patient's diagnosis)

Which of these medication orders for a patient with a pulmonary embolism is more important to clarify with the prescribing physician before administration? A. Warfarin (Coumadin) 1.0 mg by mouth (PO) B. Morphine sulfate 2 to 4 mg IV C. Cephalexin (Keflex) 250 mg PO D. Heparin infusion at 900 units/hr

1. patient's medical and social history 2. allergy status 3. cod status 4. if patient is in isolation 5. pain management strategies and response to interventions 6. imaging studies 7. lab results & location of peripheral or central venous line access devices

Which type of shift to shift report is included in the background part of the SBAR report?

patient's name nurse's title/name facility your calling from patient's name and room number admission date chief complaint diagnosis

Which type of shift to shift report is included in the situation part of the SBAR report?

1. Vital signs and range of vital signs since admission trends 2. pain assessment and pt's pain goals 3. if patient has diabetes, how frequently monitored and readings since admission 4. diagnostic studies and results 5. if patient needs turning or other therapeutic/preventative measures 6. fall risk if it applies and any other precautions specific to patient 7. medications prescribed and patients response

Which type of situation is included in the assessment part of a shift to shift SBAR report?

1. the patient's goals of care 2. what needs to be done on the next shift 3. any procedures that must be done 4. patient's education and discharge needs

Which type of situation is included in the recommendations part of a shift to shift SBAR report?

Remove the inhaler cap and shake the inhaler Hold your breath for at least 10 seconds Wait at least 1 minute between puffs

You are a team leader RN working with a student nurse. The student nurse is to teach a patient how to use an MDI without a spacer. Put in the correct order the steps that the student nurse should teach the patient. Remove the inhaler cap and shake the inhaler Tilt your head back and breathe out fully Open your mouth and place the mouthpiece 1 to 2 inches away Press down firmly on the canister and breathe deeply through your mouth Hold your breath for at least 10 seconds Wait at least 1 minute between puffs

38-year old with moderate persistent asthma awaiting discharge. A 63-year old with a tracheostomy needing tracheostomy care every shift (Rationale: Options A and B: The new RN is at an early point in her orientation. The most appropriate patients to assign to her are those in stable condition who require routine care. Option C: The patient with the lobectomy will require the care of a more experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. Option D: The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. As the new nurse advances through her orientation, you will want to work with her in providing care for these patients with more complex needs)

You are acting as a preceptor for a newly graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide care to which patients? Select all that apply. A. A 38-year old with moderate persistent asthma awaiting discharge. B. A 63-year old with a tracheostomy needing tracheostomy care every shift. C. A 56-year old with lung cancer who has just undergone left lower lobectomy. D. A 49-year old just admitted with a new diagnosis of esophageal cancer

The patient was recently in a motor vehicle accident (Rationale: Option A: Patients who have recently experienced trauma are at risk for deep vein thrombosis and pulmonary embolism. Options B, C, and D: None of the other findings are risk factors for pulmonary embolism. Prolonged immobilization is also a risk factor for DVT and pulmonary embolism, but this period of bed rest was very short)

You are admitting a patient for whom a diagnosis of pulmonary embolism must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolism? A. The patient was recently in a motor vehicle accident B. The patient participated in an aerobic exercise program for 6 months C. The patient gave birth to her youngest child 1 year ago D. The patient was on bed rest for 6 hours after a diagnostic procedure

Taking vital signs and pulse oximetry readings every 4 hours (Rationale: Option B: The nursing assistant's educational preparation includes measurement of vital signs, and an experienced nursing assistant would know how to check oxygen saturation by pulse oximetry. Options A, C, and B: Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN)

You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced nursing assistant? A. Assessing the patient's respiratory status every 4 hours B. Taking vital signs and pulse oximetry readings every 4 hours C. Checking the ventilator settings to make sure they are as prescribed D. Observing whether the patient's tube needs suctioning every 2 hours

use visual cues, such as pictures and gestures

You are caring for a patient who has had a CVA (cerebral vascular accident/ stroke) and is experiencing aphasia as a result. What would the LPN do to promote communication? A) Use visual cues, such as pictures and gestures B) Speak louder so the patient can hear you C) Refer the patient to the speech therapist in order to communicate with your patient D) Ask more questions to get more information

Maintain the head of the bed at a 30 to a 45-degree angle (Rationale: Option C: Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. Options A, B, and D: The other actions are also appropriate for this patient but will not decrease the incidence of VAP)

You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? A. Administer ordered antibiotics as scheduled B. Hyperoxygenate the patient before suctioning C. Maintain the head of the bed at a 30 to a 45-degree angle D. Suction the airway when coarse crackles are audible

The patient's respiratory rate is 8 breaths/min (Rationale: Option B: For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This patient's oxygen flow is too high and is causing a high serum oxygen level, which results in a decreased respiratory arrest. Options A, C, and D: Crackles, barrel chest, and assumption of a sitting position leaning over the night table are common in patients with chronic emphysema)

You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you immediately? A. The patient has fine bibasilar crackles. B. The patient's respiratory rate is 8 breaths/min. C. The patient sits up and leans over the night table. D. The patient has a large barrel chest

Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake (Rationale: Option C: A nursing assistant can remind the patient to perform actions that are already part of the plan of care. Options A and D: Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill and is within the scope of practice of the RNOption B: Assisting the patient in the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic nursing assistant. However, an experienced nursing assistant could assist the patient with positioning after the nursing assistant and the patient had been taught the proper technique. The nursing assistant would still be under the supervision of the RN)

You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to a nursing assistant? A. Teaching the patient about the importance of adequate fluid intake and hydration. B. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed. C. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake. D. Encouraging the patient to take a deep breath, hold it for 2 seconds, then cough two or three times in succession.

The patient is unable to remember her husband's first name (Rationale: Option C: Confusion in a patient this age is unusual and may be an indication of intracerebral bleeding associated with enoxaparin use. Options A and B: The right leg symptoms are consistent with a resolving deep vein thrombosis; the patient may need teaching about keeping the right leg elevated above the heart to reduce swelling and pain. Option D: The presence of ecchymoses may point to a need to do more patient teaching about avoiding injury while taking anticoagulants but does not indicate that the physician needs to be called.)

You are making a home visit to a 50-year old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism. The patient's only medication is enoxaparin (Lovenox) subcutaneously. Which assessment information will you need to communicate to the physician? A. The patient says that her right leg aches all night B. The right calf is warm to the touch and is larger than the left calf C. The patient is unable to remember her husband's first name D. There are multiple ecchymotic areas on the patient's arms

Pneumothorax (Rationale: The most common complication after birth for infants with RDS is pneumothorax. Alveoli rupture and air leaks into the chest and compresses the lungs, which makes breathing difficult)

You are providing nursing care for a newborn infant with respiratory distress syndrome (RDS) who is receiving nasal CPAP ventilation. What complications should you monitor for this infant? A. Pulmonary embolism B. Bronchitis C. Pneumothorax D. Pneumonia

Encouraging, monitoring, and recording nutritional intake (Rationale: Option B: The nursing assistant's training includes how to monitor and record intake and output. After the nurse has taught the patient about the importance of adequate nutritional intake for energy, the nursing assistant can remind and encourage the patient to take-in adequate nutrition. Options A and D: Instructing patients and planning activities require more education and skill and are appropriate to the RN's scope of practice. Option C: Monitoring the patient's cardiovascular response to activity is a complex process requiring additional education, training, and skill, and falls within the RN's scope of practice)

You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given a nursing diagnosis of Activity Intolerance. Which action should you delegate to the nursing assistant? A. Instructing the patient to alternate rest and activity periods B. Encouraging, monitoring, and recording nutritional intake C. Monitoring cardiorespiratory response to activity D. Planning activities for periods when the patient has the most energy

Continuous bubbling in the water seal chamber (Rationale: Option B: Continuous bubbling indicates an air leak that must be identified. With the physician's order, you can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion, which will require you to notify the physician. If the air bubbling does not stop when you apply the padded clamp, the air leak is between the clamp and the drainage system, and you must assess the system carefully to locate the leak. Option A: Chest tube drainage of 10 to 15 mL/hr is acceptable. Option C: The patient's complaints of pain need to be assessed and treated. This is important but is not as urgent as investigating a chest tube leak. Option D: Chest tube dressings are not changed daily but may be reinforced)

You are supervising a nursing student who is providing care for a patient with thoracotomy with a chest tube. What findings would you clearly instruct the nursing student to notify you about immediately? A. Chest tube drainage of 10 to 15 mL/hr. B. Continuous bubbling in the water seal chamber. C. Complaints of pain at the chest tube site. D. Chest tube dressing dated yesterday.

The patient's blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min (Rationale: Option C: Removal of large quantities of fluid from the pleural space can cause fluid to shift from the circulation into the pleural space, causing hypotension and tachycardia. The patient may need to receive IV fluids to correct this. Options A, B, and D: The other data indicate that the patient needs ongoing monitoring and/or interventions but would not be unusual findings for a patient with this diagnosis or after this procedure)

You have just finished assisting the physician with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is important to report to the physician? A. The patient starts crying and says she can't go on with treatment much longer. B. The patient complains of sharp, stabbing chest pain with every deep breath. C. The patient's blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min. D. The patient's dressing at the thoracentesis site has 1 cm of bloody drainage.

pain rating that has decreased from a 10 to 0 in a patient who is awaiting an appendectomy

You have just received nursing report from the previous shift and you are performing your morning patient assessments. You have a total of 4 patients that are either post-op or pre-op for surgery. Which assessment finding requires further nursing action? (priority question "further nursing action= priority) a. Orange-colored urine in a patient who is taking Pyridium and is post-op day 3 from a TURP b. No stool excretion in a patient who is post-op day 2 from a colostomy c. Shoulder pain in a patient who is post-op day 1 from a laparoscopic cholecystectomy d. pain rating that has decreased from a 10 to 0 in a patient who is awaiting an appendectomy

Frequent swallowing (Rationale: Frequent swallowing after a tonsillectomy may indicate bleeding. You should inspect the back of the throat for evidence of bleeding. The other assessment results are not unusual in a 3-year old after surgery)

You have obtained the following assessment information about a 3-year old who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow-up? A. Frequent swallowing B. Hypotonic bowel sounds C. Complaints of a sore throat D. Heart rate of 112 beats/min

prodromal stage

Your patient has developed a low-grade fever and states that she has felt very tired lately. You interpret these findings as indicating which stage of infection? a. Incubation period b. Prodromal stage c. Full stage of illness d. Convalescent period

C-diff (clostridium difficile: enteric infections) RSV, influenza (respiratory infections) certain contact precautions like bleach must be used in case of C-diff

contact precautions

leadership

how a person empowers and develops a team to meet and exceed patient and institutional outcomes

prodromal stage

the onset of general symptoms to more distant symptoms; the pathogen is multiplying (stages of infection) - happens the quickest i.e. fatigue

battery

treating a client without consent to cause physical harm

Assertive

• "Taking a positive stand, being confident in your statement, or being positive in a persistent way." • The following three rules are helpful overall in being assertive: • 1. OWN YOUR FEELINGS. DO NOT BLAME OTHERS FOR THE WAY YOU FEEL. • 2. MAKE YOUR FEELINGS KNOWN BY BEING DIRECT. BEGIN YOUR STATEMENTS WITH "I." • 3. BE SURE THAT YOUR NONVERBAL COMMUNICATION MATCHES YOUR VERBAL MESSAGE. • YOU ARE READY TO LEAVE WORK WHEN A PEER APPROACHES VOU ABOUT A PERSONAL PROBLEM. YOU RESPOND BY SAYING, "I HAVE TO LEAVE NOW, BUT I'LL BE GLAD TO LISTEN TO YOU DURING OUR LUNCH BREAK TOMORROW" • YOUR DAY IS OVERWHELMING. YOU APPROACH YOUR TEAM LEADER AND SAY, "I KNOW YOU WOULD LIKE ALL OF THIS DONE TODAY. THERE IS NO WAY I CAN GET IT ALL DONE, WHAT ARE YOUR PRIORITIES?"

Aggressive

• Is an attack on the person rather than on the person's behaviors. • "You do not count. I count." message • You have asked to go to a workshop, and the supervisor says "Why should you go? everyone else has worked here longer than you have" • "You have had your light on continuously for nothing all morning. Do not put your light on again unless you are dying or I will take it away ."

Passive

• Nonassertive nurses attempt to look the way avoid conflict, and take what seems to be easiest way out • Telling another nurse HOW "STUPID/' THE DOCTOR ORDERING A CERTAIN TYPE OF TREATMENT • Limiting contact with a patient he or she is uncomfortable with to required care only • Needing help with an assignment but saying nothing (REFRAINS FROM EXPRESSING OWN NEEDS)