Leadership, Delegation, and Emergency Response Planning
The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and have a licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? 1. A client who requires a bed bath 2. An older client requiring frequent ambulation 3. A client who requires hourly vital sign measurements 4. A client requiring abdominal wound irrigations and dressing changes every 3 hours
Answer: 4 Explanation: Page 89
The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? 1. A postoperative client preparing for discharge with a new medication 2. A client requiring daily dressing changes of a recent surgical incision 3. A client scheduled for a chest x-ray after insertion of a nasogastric tube 4. A client with asthma who requested a breathing treatment during previous shift
Answer: 4 Explanation: Page 88
The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? SATA 1. The acuity level of the clients 2. Specific requests from the staff 3. The clustering of the rooms on the unit 4. The number of anticipated client discharges 5. Client needs and workers' needs and abilities
Answer: 1, 5 Explanation: Page 89
The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? SATA 1. Open doors to client rooms 2. Move beds away from windows 3. Close window shades and curtains 4. Place blankets over clients who are confined to bed 5. Relocate ambulatory clients from the hallways back into their rooms
Answer: 2, 3, 4 Explanation: Page 89
The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for. an assistive personnel (AP)? 1. A client requiring a colostomy irrigation 2. A client receiving continuous tube feedings 3. A client who requires urine specimen collections 4. A client with difficulty swallowing food and fluids
Answer: 3 Explanation: Page 89
A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice?: 1. Each staff member is assigned a specific task for a group of clients. 2. A staff member is assigned to determine the client's needs at home and begin discharge planning. 3. A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an unlicensed assistive personnel (UAP). 4. An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients.
Answer: 4 Explanation: Page 88
The nurse employed in an emergency department is assigned to to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? 1. A client complaining of muscle aches, a headache, and a history of seizures 2. A client who twisted her ankle when rollerblading and is requesting medication for pain 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
Answer: 4 Explanation: Page 88
The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1. A client who is ambulatory demonstrating steady gait 2. A postoperative client who has just received an opioid pain medication 3. A client scheduled for physical therapy for the first crutch-walking session 4. A client with a white blood cell count of 14,000mm^3 (14 x 10^9/L) and a temperature of 38.4 C.
Answer: 4 Explanation: Page 88
The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1. Finish the bed bath and then administer the pain medication to the other client 2. Ask the AP to find out when the last pain medication was given to the client 3. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client
Answer: 4 Explanation: Page 88
The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP? 1. Ignore the resistance 2. Exert coercion on the AP 3. Provide a positive reward system for the AP 4. Confront the AP to encourage verbalization of feelings regarding the change
Answer: 4 Explanation: Page 88
