FUNDAMENTALS WEEK 4
A charge nurse is reviewing client acuities and tasks to make the nursing staff's daily assignments. When using the Five Rights of Delegation, which of the following should the charge nurse use to ensure client safety? a. Right scope b. Right direction c. Right supervision d. Right task
d. Right task
A nurse is assisting with teaching a class about HIPPAA. Which of the following information should the nurse include? (select all that apply) - HIPPAA protects the unauthorized release of a client's protected health information - HIPPAA prohibits clients from obtaining their medical record -HIPPAA requires notification of a breach privacy via an in-person report -The loss of a provider's cell phone that contains a client's protected health information is considered a data breach -A breach in HIPPAA should be reported within 60 days after the breach is discovered
- HIPPAA protects the unauthorized release of a client's protected health information -The loss of a provider's cell phone that contains a client's protected health information is considered a data breach -A breach in HIPPAA should be reported within 60 days after the breach is discovered
Some conditions that would require the nurse to notify rapid response team (RRT)
- sudden change in vital signs -low oxygen saturation despite efforts to oxygenate the client -chest pain despite the administration of nitroglycerine -seizure - medical professional has a deep concern about the client's condition - sudden change in the client's mental status
Two methods used to ensure continuity of care
-Quality assessment skills -Consistent client monitoring
Near miss
A potential error or event that could have caused har, but was caught or avoided
which extinguisher is a multipurpose fire extinguisher?
A-B-C fire extinguisher
Electronic Monitoring Devices
Form of telehealth medicine that assists in tracking client data and facilitates the immediate transfer of information to the health care provider. Ex: implantable devices and monitors that are worn on the body
What is the importance of time management to a nurse?
It helps the nurse be more efficient and less stressed and improves client outcomes
How should the nurse deal with the client who is chemically impaired?
Remove self from the situation; request restraints
5 rights of delegation
Right task Right circumstance Right person Right directions and communication Right supervision and evaluation
Which priority elements should be done if an active shooter is in the workplace? Identify their correct priority order
Run, Hide, Fight
Telehealth
Using telecommunications and video conferencing to provide client care outside the typical clinical setting
A charge nurse is reinforcing teaching with a group of nurses about protecting themselves from an abusive client. Which of the following statements by a nurse within the group demonstrates an understanding of the teaching? a. "I should try to escape or put a barrier between myself and the client." b. "I should never hit an abusive client since they cannot control themselves." c. "The client must physically harm me for it to be abuse." d. "Nurses are rarely the subject of abusive clients."
a. "I should try to escape or put a barrier between myself and the client."
Seclusion
isolation from others, solitude
Name two client identifiers
name,date of birth, designated hospital number, or telephone number
3 principles that should be followed to assure radiation safely
reduce time near the source of radiation, increase distance from the source of radiation, and implement shielding
Informatics
use information and technology to communicate, manage knowledge, mitigate error, and support decision making
HIPPAA
Health Insurance Portability & Accountability Act
What is mnemonic to remember how to use a fire extinguisher?
P.A.S.S. Pull Aim Squeeze Sweep
A nurse is reinforcing teaching with a class assisting with the use of smart infusion pumps to administer intravenous medications. Which of the following information should the nurse include? a. Nurse should use workarounds when using smart infusion pumps b. The use of smart infusion pumps is associated with increased medication errors c. Nurses enter client information into the smart infusion pump d. The smart infusion pump alerts the nurse when the setting is within the safety limits
c. Nurses enter client information into the smart infusion pump
A nurse is precepting a newly licensed nurse and suggests using the IDEAL method to structure the client's discharge planning. The client's caregiver is also in the room. Which of the following statements made by the newly licensed nurse demonstrates the correct use of IDEAL method? a. "I will set SMART goals for the client's recovery" b. "I will provide the client with a list of medications to take home." c. "I will provide education about the client's condition in a booklet." d. "I will include the client and caregiver in the discharge discussion."
d. "I will include the client and caregiver in the discharge discussion."
A newly licensed nurse is reviewing the clients assignments for a shift and determining tasks to complete. Which of the following is a time management strategy the nurse should use? a. Instruct the assistive personnel on a task outside their range of function b. Make a list and prioritize a plan c. Dispense all of the day's scheduled medications together d. Document client care at the end of the day
b. Make a list and prioritize a plan
Health Literacy
ability to read, understand, and act on health information
four hospital-acquired infections monitored by CDC
-Central line associated bloodstream infection (CLABSI) -Catheter-associated urinary tract infection (CAUTI) -Surgical site infection (SSI) - Ventilator Associated pneumonia (VAP)
A nurse is reviewing discharge instructions with a client who has low health literacy. Which of the following actions should the nurse take? a. Speak quickly b. Provide examples c. Discourage questions d. Use medical terminology
b. Provide examples
A nurse is reviewing the HIPPAA regulatory rules. Which of the following rules is restricted to electronic protected health information (e-PHI)? a. The Privacy Rule b. The Security Rule c. The Breach Notification Rule d. The Enforcement Rule
b. The Security Rule
A nurse is caring for a client who is being transferred to another unit, but the receiving nurse is unavailable to take report. Which of the following concepts is being violated that could place the client at risk? a. Quality assessment skills b. Interprofessional collaboration c. Continuity care d. Consistent client monitoring
c. Continuity care
Sentinel event
critical, unexpected adverse event that caused severe physical or psychological harm to a client, including death and dismemberment, permanent injury, and severe or temporary injury
A nurse is preparing to use a vide-enabled device to communicate with a client who is at home. Which of the following actions should the nurse plan to take? a. Record the video conference to use as an educational tool b. Inform the client that telemedicine restricts access to nursing care c. Use a speakerphone in a semi-private location during the video conference d. Instruct the client to use a computer for video conference
d. Instruct the client to use a computer for video conference
A nurse is assisting with teaching a client about remote patient monitoring (RPM) devices. Which of the following information should the nurse include? (select all that apply) - The client needs to confirm the data before it is transferred to the provider - The transfer of data is accomplished using wireless devices - Clients can participant in their health by using RPM - A client's heart rhythm can be transferred using RPM - Data collected using RPM is not considered protected health information
- The transfer of data is accomplished using wireless devices - Clients can participant in their health by using RPM - A client's heart rhythm can be transferred using RPM
A nurse is completing a medication reconciliation on a newly admitted client. Which of the following information should the nurse include? (select all that apply) -Current prescribed medications - Nutritional supplements the client takes - Over-the-counter medications the client uses - Medications the provider has discontinued - List of vitamins the client has stopped taking
-Current prescribed medications - Nutritional supplements the client takes - Over-the-counter medications the client uses
A nurse is renewing the role of health information technology in client care with a newly licensed nurse. Which of the following information should the nurse include? (select all that apply) -Facilitates care coordination - Increase human error - Improves practice efficiencies - Is capable of being overridden by a nurse -Improves clinical outcomes
-Facilitates care coordination - Improves practice efficiencies - Is capable of being overridden by a nurse -Improves clinical outcomes
2 network practices that have increased the amount of time th =e nurse spends at the client'sbedside
Hourly rounding and bedside handoff communication
A nurse is reinforcing teaching about the use of the SMART goal method with a client who has diabetes mellitus and is setting nutrition and weight loss goals. Which of the following client statements should indicate to the nurse an understanding the teaching? a. "I will reduce my sugar intake by 10 grams each week for 1 month until I reach the desired level." b. "I will cut all carbs out of my diet until I lose 25pounds." c. "I will keep my calories at 1,000a day so I can lose several pounds over time." d. "I need to lose 25 pounds and stop eating all the foods I love."
a. "I will reduce my sugar intake by 10 grams each week for 1 month until I reach the desired level."
A nurse is assisting with teaching a newly licensed nurse about the use of electronic health records (EHRs). Which of the following is an outcome associated with the use of EHRs that the nurse should include? a. Saves time b. Decreases quality of care c. Creates redundancy d. Increases cost
a. Saves time
When should medication reconciliation be conducted?
at admission, upon discharge, or when the client is transferred to another level of care within the facility or to another care facility
A nurse is reviewing the impact low health literacy has for clients with a newly licensed nurse. Which of the following information should the nurse include? a. Decrease in health care cost b. Decrease in use of emergency services c. Increase in mortality rate d. Increase in use of preventative services
c. Increase in mortality rate
A nurse is discussing clinical pathways with a newly licensed nurse. Which of the following information should the nurse include? a. Paper-based clinical pathways are more effective than computer-based b. The use of clinical pathways has led to a decline in client outcomes c. Insurance companies discourage the use of clinical pathways d. Clinical pathways use evidence-based practice guidelines for health care delivery
d. Clinical pathways use evidence-based practice guidelines for health care delivery
A charge nurse is reinforcing teaching with a newly licensed nurse about the concept of team nursing. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. "Nurses will pair together to care for an assigned group of client's." b. "Nurses will be responsible for performing total care on clients." c. "I have never worked in ICU. I cannot take care of ventilated clients." d. I will be caring for a group of clients with an assistive personnel."
a. "Nurses will pair together to care for an assigned group of client's."
A nurse is assisting with teaching a class about using simulation for clinical education. Which of the following information should the nurse include? a. The use of simulation improves communication skills b. Simulation should be used in pace of clinical practice c. Simulation is a competent of nursing theory d. The use of simulation is expected to decrease
a. The use of simulation improves communication skills
A nurse is speaking with a client who is noncompliant in performing a daily blood glucose testing regimen. Which of the following responses should the nurse make? a. "It is important that you monitor your blood glucose, or you can have more health problems." b. "What is preventing your consistency with your daily blood glucose checks?" c. "Explain why you are not doing your daily checks as prescribed." d. "Do you understand the purpose of the daily checks?"
b. "What is preventing your consistency with your daily blood glucose checks?"
A nurse is assisting with teaching a newly licensed nurse about using barcode technology in client care. The nurse should include that barcode technology is used to reduce errors during which of the following phases of the medication process? a. Prescribing b. Transcribing c. Administering d. Dispensing
c. Administering
A nurse is reviewing the use of electronic documentation with a newly licensed nurse. Which of the following statements should the nurse make? a. "Electronic documentation increase paperwork." b. "Electronic documentation increases the time available to provide direct client care." c. "Electronic documenting takes approximately 10 percent of your time." d. "Electronic documentation provides evidence of care provided."
d. "Electronic documentation provides evidence of care provided."
A nurse is assisting with teaching a class about using health information technology for client care. Which of the following examples should the nurse include? a. Using a roller clamp to adjust a client's IV rate b. Using a barcode to verify a client's medication c. Palpating a client's blood pressure d. Wearing sterile gloves to change a client's dressing
b. Using a barcode to verify a client's medication
A nurse is giving change-of-shift report to an oncoming nurse using SBAR reporting. Which of the following entries by the nurse demonstrates the correct use of SBAR? a. The client in room 1 is postoperative exploratory laparotomy surgery yesterday. No complications besides some post-operative pain b. The client in room 1 states "pain is a 4 out of 10" despite pain medication. Vital signs are stable. No outward manifestations of distress. Plan to call the provider if it continues. c. The client in room 1 has been experiencing breakthrough pain following an exploratory surgery yesterday. Vital signs are stable. Recommended calling the provider for a breakthrough dose if pain continues. d. The client in room 1 had surgery and is experiencing pain post- operative. By the end of his shift, the client will have pain controlled, with a pain of no more than a 2 out of 10 without breakthrough pain. or need additional medications for breakthrough pain.
c. The client in room 1 has been experiencing breakthrough pain following an exploratory surgery yesterday. Vital signs are stable. Recommended calling the provider for a breakthrough dose if pain continues.