Leadership Review

The RN, LPN, and unlicensed assistive personnel (UAP) are providing care for clients on the nursing unit. Which tasks could be completed only by the RN? Select all that apply 1. Administration of routine medications. 2. Dressing changes. 3. Assessment of newly admitted clients. 4. Calling the primary healthcare provider about lab results. 5. Teaching the diabetic client foot care.

3. & 5. Correct: Admission assessments and teaching must be performed by the RN. The nursing process, along with teaching are outside the scope of practice of the LPN. These are tasks that must be performed by the RN. The LPN can reinforce teaching. 1. Incorrect: Medication administration is within the LPN scope of practice and can be completed by the LPN. 2. Incorrect: Dressing changes may be delegated to the LPN as this is within the LPN scope of practice. 4. Incorrect: The LPN may call lab results to the primary healthcare provider because this is within the scope of practice for the LPN. If any additional prescriptions are required, the LPN can take these prescriptions over the phone.

What clients could safely be delegated to the LPN/VN? Select all that apply 1. A client two days post appendectomy needing to ambulate. 2. A client with bronchitis receiving nebulizer treatments. 3. A newly diagnosed diabetic client awaiting discharge home. 4. A client newly admitted with exacerbation of myasthenia gravis. 5. A client admitted yesterday for observation following a fall. 6. A client with a nasogastric tube (NG) hooked to low suction.

Remember: An LPN/VN cannot assess, evaluate, create a plan of care, or do initial teaching. An LPN/VN can "re-evaluate" teaching to see if the client understands, but cannot initiate new instruction. Another important aspect to remember is that you cannot "assume" information that is not specifically provided in the question. 1, 2, 5 & 6. Correct: Thes clients are appropriate and stable enough for the LPN/VN's scope of practice. While an LPN/VN cannot be assigned a fresh post-op, the first client had an appendectomy two days ago. The LPN/VN could even delegate ambulating this client to unlicensed assistive personnel (UAP). A client with bronchitis will need a respiratory assessment by the RN at some point, but the LPN/VN is definitely qualified to administer aerosol treatments. The third client was admitted for observation following a fall a day ago, indicating no injuries serious enough for a full admission. PNs can insert and monitor NG tubes. 3. Incorrect: This client is a newly diagnosed diabetic who will require extensive teaching about selfcare at home. Additionally, discharging a client always involves teaching, which cannot be initiated by an LPN/VN. This option does not indicate that any teaching had been presented, so the client is not an appropriate assignment for the LPN/VN. 4. Incorrect: Myasthenia Gravis is a progressive weakening of the neuromuscular system placing the greatest risk on the respiratory system. Although this client is on a medical-surgical floor, there is a need for close monitoring and frequent assessment of the respiratory system, requiring an RN.

The charge nurse on the Labor and Delivery unit is making morning assignments. What client would be most appropriate for a newly hired licensed practical nurse (LPN)? 1. Assist with bottle feeding newborns in the nursery. 2. Completing perineal care for post-delivery clients. 3. Observing a Cesarean section for co-joined twins. 4. Ambulate client to bathroom following delivery.

There are several clues in this question which present important information. First, note this LPN is newly hired, which would indicate either orientation or learning is still in progress. Secondly, the charge nurse is to make an actual client assignment. 2. Correct: The general scope of practice for a licensed practical nurse (LPN) includes the completion of tasks with predictable outcomes. Completing perineal care is definitely within the LPN's scope of practice. If any irregularities are noted, such as amount or color of drainage, the LPN would report this to the RN for further assessment. 1. Incorrect: Although bottle feeding may sound like a simple task, there are multiple on-going assessments involved with newborns. A nurse must evaluate whether the infant can latch on, has an appropriate sucking reflex, or if the newborn displays any allergic reactions to the milk. This task should be designated to an experienced nurse rather than the LPN. 3. Incorrect: While it is not inappropriate for a newly hired LPN to observe this unique surgery, it would not help orient or prepare the individual for working on the unit. The LPN should be preparing for other duties or working with a preceptor to learn the floor routine. 4. Incorrect: A number of staff members could ambulate clients to the bathroom, including the LPN or unlicensed assistive personnel (UAP). This task could easily be designated to the UAP, allowing the charge nurse to better utilize the LPN's abilities within the scope of practice.

The client expresses concern to the nurse about the ability to provide self-care and perform activities of daily living at discharge. Which member of the healthcare team should the nurse contact to provide information and assist the client with resources for an effective discharge plan? 1. Primary healthcare provider 2. Case manager 3. Physical therapist 4. Occupational therapist

2. Correct: The client's case manager should be contacted regarding the order for pending discharge from the healthcare facility. The case manager coordinates care and provides the client with information and resources for an individualized discharge plan. 1. Incorrect: The primary healthcare provider does not assume the case management role in the acute care facility setting, and generally does not coordinate the discharge planning process. 3. Incorrect: The physical therapist is a member of the multidisciplinary team and might help evaluate, but does not coordinate discharge planning. They are not responsible for case management and coordination of overall client care for discharge from the facility. 4. Incorrect: The occupational therapist is a member of the multidisciplinary team and might help evaluate, but does not coordinate discharge planning. They are not responsible for case management and coordination of overall client care for discharge from the facility.

Which assignment would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Totaling I & O records on five clients at the end of the shift. 2. Assessing VS on a client who was admitted 30 minutes ago. 3. Administering nasogastric (NG) tube feeding. 4. Changing an abdominal surgical dressing on a client that is 3 days post op.

1. Correct: Totaling I & O is an appropriate task for a UAP to be assigned. This is within the scope of practice for the UAP. 2. Incorrect: New clients should be assessed by an RN; however, it is acceptable for the RN to get assistance with some of the information. The RN must verify all information. The client is a new admit, and is considered unstable; therefore, the RN should get the baseline vitals. 3. Incorrect: Administering a NG tube feeding is not within scope of practice for the UAP. 4. Incorrect: Changing a surgical dressing is not within the scope of practice for the UAP.

Which tasks can the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply 1. Reporting lab results to the client 2. Measuring intake and output 3. Discontinuing an IV 4. Discussing client condition with the client's spouse 5. Performing oral hygiene for an older client

2. & 5. Correct: Measurement of intake and output and oral hygiene for the older client are tasks that the UAP can perform, and these tasks may be delegated. 1. Incorrect: Reporting of lab results should be accomplished by the nurse who has the knowledge to interpret results. This is not appropriate for the UAP and must be done by a licensed nurse. 3. Incorrect: Removal of the IV requires assessment skills that the unlicensed assistive personnel does not have. 4. Incorrect: Discussion of client's condition should be done by the nurse with the client's permission.

A nurse on the unit has had a disagreement with the family of a client regarding the client's dressing change. What is the best action by the nurse manager? 1. Meet with the family member and the RN to discuss the disagreement. 2. Assure the family member that the nurse followed the hospital procedure. 3. Discuss the dressing change procedure with the RN and compare to a current textbook. 4. Report the argument to the hospital administrator.

1. Correct: When conflict occurs, meet with both parties together to discuss the problem. Each party can hear what the other is saying and the nurse manager is not caught in the middle. They will be able to come up with solutions together or the manager can mediate. 2. Incorrect: It is ok to clarify that the nurse followed hospital procedure. However, the nurse is sing the nontherapeutic communication technique of blocking. The family member may still believe that there is another procedure that could have been initiated. 3. Incorrect: You may want to do this as well, but it will not address the conflict. The conflict is that the family member disagrees with the nurse's procedure for dressing change. 4. Incorrect: The nurse manager must try to resolve the conflict between the family member and the nurse first. If the conflict cannot be resolved the nurse manager would notify the person that is next in the chain of command.

The nurse educator has provided education to newly hired emergency department nurses regarding mandatory reporting laws. Which suspected instances provided by the new nurses indicates to the nurse educator that education was effective? Select all that apply 1. Financial abuse of an elder 2. Negligence of a colleague 3. Spousal abuse denied by the victim 4. Gunshot victim 5. Client diagnosed with Gonorrhea 6. Client diagnosed with West Nile virus

1., 4., 5., & 6. Correct: Federal and state laws require that certain individuals, particularly those who work in health care with the elderly, with children, and other vulnerable populations, have an affirmative duty to report to a specified state agency when violence occurs against those populations. This includes physical, mental, and financial abuse. Gunshots and knife injuries are reportable to law enforcement. Certain communicable diseases such as gonorrhea and West Nile virus are reportable to the CDC. 2. Incorrect: Suspected negligence of a colleague is not in the realm of mandatory reporting to authorities, but the nurse should discuss with the supervisor. 3. Incorrect: A spouse is not considered a vulnerable person so it is not required by law to report. You should encourage the spouse to report the abuse but you, as the nurse, are not bound by law to do so.

A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). Which of the following RNs should not be assigned to this baby? 1. A nurse just back from maternity leave. 2. A nurse who is 10 weeks pregnant. 3. A nurse who is breastfeeding her 4 month old. 4. A nurse who is on hormone replacement therapy.

2. Correct: Cytomegalovirus is a viral infection that can be devastating to a fetus, especially in the first trimester. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. 1. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. 3. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. 4. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure.

Which tasks can the RN delegate to an unlicensed assistive personnel (UAP) when caring for a client who has had a stroke and is being rehabilitated? Select all that apply 1. Assess a client's ability to swallow. 2. Develop a plan of care for hygiene needs. 3. Assist the client using a walker. 4. Calculating the intake and output. 5. Encourage and assist the client with the use of a hairbrush on the affected side. 6. Teach the family about the need to prevent pressure ulcers.

3., 4. & 5. Correct: It is within the role of the UAP to assist a client with a walker. The UAP can collect and calculate intake and output. When assisting the client with hygiene needs, the UAP can promote strengthening of the affected side by encouraging and assisting the client to place the hairbrush in the hand of the affected side. 1. Incorrect: The UAP cannot assess a client. Assessment is not in role of the UAP and is also outside the scope of practice for LPN's. Assessments must be performed by the RN. 2. Incorrect: Although the UAP can provide care and assistance related to hygiene needs, the planning of care cannot be delegated to the UAP. This is part of the nursing process and must be performed by the RN. 6. Incorrect: Teaching cannot be delegated to the UAP and is also outside the scope of practice for the LPN. Teaching is a responsibility and in the scope of practice for the RN.

An injured client brought to the emergency room by ambulance insists on leaving before being seen by the primary healthcare provider. What is the nurse's priority action? 1. Explain potential risks of leaving without proper care. 2. Insist the client sign "Against Medical Advice" form. 3. Calmly convince client to wait for needed treatment. 4. Notify primary healthcare provider immediately.

4. Correct: The nurse's priority is to inform the primary healthcare provider immediately about the client's decision to leave. The client's injuries need evaluated and potential risks of non-treatment to those injuries thoroughly explained. Only the HCP can detail specifics, and has the authority to try to convince the client to wait for treatment. 1. Incorrect: The client must be informed about the potential risks of leaving without medical treatment and that information is best explained by either the emergency room healthcare provider or primary healthcare provider based on knowledge of the client's potential injuries. 2. Incorrect: An "Against Medical Advise" (AMA) form is designed to protect staff and facility from potential litigation filed by clients leaving without treatment. However, a client cannot be forced to sign the form and this is not the nurse's priority action. 3. Incorrect: The nurse can use therapeutic techniques to discuss the situation and try to discover why the client wants to leave. However, there is another priority more important for the nurse.

A fully alert and competent client is in end-stage cardiac disease. The client says, "I'm ready to die," and refuses to take nourishment. The family urges the client to allow the nurse to insert a feeding tube. What action should the nurse take? 1. Tell the family that the feeding tube will be inserted after the client becomes unresponsive. 2. Ask the primary healthcare provider to have the dietitian talk with the client about food preferences. 3. Notify the case manager to arrange a meeting with the client's family . 4. Provide additional information as requested by the client concerning nourishment.

4. Correct: This client is alert and competent, and has the right to make healthcare decisions and the right to die with dignity. The nurse should provide any additional information as requested by the client. 1. Incorrect: This is inappropriate, as it does not follow the client's wishes and would be a violation of client rights. 2. Incorrect: The client has made the decision to refuse nourishment so this action ignores this decision and violates client rights. 3. Incorrect: The nurse should honor the client's wishes first. The family would only need to meet if the client became unable to make decisions on their own. Even so, these decisions could not violate any advance directives that were in place.

The charge nurse is delegating assignments on the Alzheimer's unit of a long-term care facility. What task could be assigned to the unlicensed assistive personnel (UAP)? Select all that apply 1. Replace soiled heel protectors on bedfast client. 2. Provide TUMS to client reporting heartburn. 3. Trim fingernails on confused diabetic client. 4. Escort dementia client on an outdoor walk. 5. Assist client to complete the daily menu list.

1, 4 & 5.Correct: The tasks appropriate for the unlicensed assistive personnel (UAP) focus on activities of daily living. Replacing any item of clothing, including heel protectors, is appropriate for the UAP. Ambulating a client outside is an excellent activity to delegate to the UAP, in addition to helping a client complete the diet menu. The UAP can read the selections to the client and mark the choice. 2. Incorrect: When a client reports heartburn, there are potential issues requiring assessment by the RN. The client may actually be experiencing a cardiac event which would require intervention and contacting the primary healthcare provider. Though TUMS is an over the counter product, it is still considered a medication and should be administered nursing staff. 3. Incorrect: Did you hesitate here, thinking that fingernails were acceptable? This was a difficult choice, no doubt. Ordinarily a UAP can indeed trim fingernails, as long as they are cut directly across. However, note that this client is diabetic and is also confused. Consider the potential for injury when cutting this client's nails. This risky task should be completed by a nurse.

Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? Select all that apply 1. Soaking the dentures in hot water 2. Donning gloves and using a gauze pad to grasp and remove dentures 3. Moistening the dentures prior to inserting them 4. Wrapping the dentures in tissue while the client sleeps 5. Placing a washcloth in the bathroom sink prior to cleaning.

1. & 4. Correct: Hot water may damage dentures so intervention is needed. Hot water can make denture material sticky. Cool water should be used. Wrapping dentures in tissue may cause them to be accidentally thrown away. Dentures should be stored in a denture cup. 2. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. 3. Incorrect: Moistening the dentures will ease insertion. 5. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped.

The nurse manager is planning a leadership development workshop for new charge nurses. Which components of the communication cycle should the manager include as necessary for effective verbal communication? Select all that apply 1. There is a sender for every message. 2. A clear message is formulated. 3. There is a receiver for every message. 4. The sender and receiver share the same life experiences. 5. There can be incongruence between the verbal and nonverbal message.

1., 2. & 3. Correct: The communication cycle includes the sender, a clear and concise message, the receiver, plus verbal or nonverbal feedback to acknowledge understanding of the message. The sender is the person who delivers the message, and the receiver is the person who receives the message. 4. Incorrect: The sender and receiver may not share the same life experiences; however, therapeutic communication can still be achieved. The more the sender and receiver have in common and the closer the relationship, the more likely they will accurately perceive one another's meaning and respond accordingly. However, this is not required for effective verbal communication. 5. Incorrect: There should be congruence between verbal and nonverbal communication. Incongruence can lead to misunderstanding and miscommunication.

Which task would be appropriate for the nurse to assign the unlicensed assistive personnel (UAP)? 1. Assess any pressure ulcers noted on clients. 2. Report if any client indicates pain. 3. Monitor amount of chest tube drainage. 4. Demonstrate coughing and deep breathing exercises to post-op clients.

2. Correct. It is within the scope of practice for the UAP to ask the client if they are experiencing pain. The nurse will then assess the pain. The nurse can delegate, assess, develop a plan of care and evaluate. 1. Incorrect. This is an RN task. The UAP does not have the appropriate education to assess a pressure ulcer. This is not within their scope of practice. 3. Incorrect. The UAP cannot assess or evaluate. This is an RN task. Monitoring the amount of chest tube drainage is an appropriate action for the nurse. The UAP cannot monitor the amount of chest tube drainage. 4. Incorrect. The UAP cannot teach. This is an RN task. The nurse cannot delegate teaching or demonstrating to the UAP. This is the responsibility of the RN.

The house supervisor has sent an LPN to assist on a busy medical-surgical unit. Which clients could the charge nurse assign to the LPN? Select all that apply 1. Discharged with a new Hickman port. 2. With a deep vein thrombosis (DVT) on a heparin infusion. 3. Two-days post gastric bypass taking clear liquids. 4. With Alzheimer's disease awaiting transfer to nursing home. 5. Newly arrived from PACU following a mastectomy.

3 and 4. CORRECT: An LPN should be assigned stable clients who do not require initial teaching or frequent assessments. The client who is two days post gastric bypass has already advanced to clear liquids and would be appropriate for an LPN. Also, a client who has Alzheimer's disease awaiting transfer would have needs that could be addressed by an LPN, and therefore is a suitable assignment. 1. INCORRECT: This client has a new Hickman port which is an implanted access device used for chemotherapy or medications given long term. There is a great deal of teaching necessary regarding the care of this port. This client should be assigned to an RN. 2. INCORRECT: This client will need frequent assessment of circulation in the area of the DVT and monitoring for evidence of bleeding complications. Additionally, PTT levels will be drawn every 6 hours that may require the nurse to adjust the heparin infusion rate. This client is not appropriate for an LPN. 5. INCORRECT: This fresh post-op client will require frequent vitals and assessment of the surgical dressing following this surgery. This client would be assigned to an RN.

A nurse walks into the medication area of a long-term care facility and sees a colleague taking a pill from a resident's supply of narcotics. The nurse says, "Please don't say anything. I need my job and I have a migraine." What actions should the nurse take? Select all that apply 1. Reassure the colleague that she won't tell this time. 2. Insist that the colleague get some help. 3. Report what was seen to the supervisor. 4. Send the colleague home. 5. Follow procedure to return medication to the resident's supply.

3. & 5. Correct: The nurse should follow the procedure to return the narcotic, and then the nurse should report the observation to the supervisor. The nurse must serve as client advocate by reporting a nurse who may be impaired. 1. Incorrect: This may be the first observation; however, it is unlikely that it is the first incidence. The impaired nurse must be reported. You are responsible to the clients on the unit, not to the staff member. 2. Incorrect: The supervisor is the one to provide information on obtaining help. The hospital or long term care facility will have a policy for the supervisor to follow and usually this policy also includes rehabilitation. The nurse may say okay to you if you tell them to get help, but then never seek help. The person caught will generally do or say anything to keep the authorities from finding out. As a colleague you can offer support, but don't go there alone. 4. Incorrect: The nurse should leave if she is taking narcotics. The supervisor will be the one to send the nurse home. The supervisor needs to determine if the degree of impairment would interfere with the ability to drive home safely. Note on impaired nurses: Impaired nurses can become dysfunctional in their ability to provide safe, appropriate client care. Addiction is considered a disease, but the addicted nurse remains responsible for actions when working. Nurses should be aware of the signs and symptoms of substance abuse and know when to report a coworker suspected of substance abuse to management. While it may be very difficult to suspect a co-worker of substance abuse, and the fear of reprisal may keep some nurses from action, it's important to take the steps necessary to confront or notify the nurse manager of your suspicions. Educate yourself on the organization's policy and procedures for employee substance abuse and employee assistance programs. Careful documentation of any changes in the suspected impaired nurses' behaviors is important. Legal aspects to report a substance-abusing nurse vary among individual states, but nurses have an ethical and moral duty to clients, colleagues, the profession of nursing, and the community to take action. Documents such as the American Nurses Association Code of Ethics for Nurses provide a framework for client safety. Consider the following: Do not ignore poor performance; Do not lighten or change the nurses' patient assignment.; Do not accept excuses; Do not allow yourself to be manipulated or fear confronting a nurse if patient safety is in jeopardy.

A client diagnosed with confusion and dehydration is admitted to the medical unit. The RN is working with an LPN and an unlicensed assistive personnel (UAP). Which tasks would be best for the RN to assign to the LPN? Select all that apply 1. Insert an indwelling urinary catheter 2. Reinforce the teaching plan with the client's family 3. Maintain fluids at bedside 4. Assess I & O for adequate fluid replacement 5. Obtain daily weights

1. & 2. Correct: The LPN can insert a indwelling urinary catheter since hourly urinary output measurements are needed, this is within the scope of practice. The LPN can reinforce an already prepared teaching plan, but cannot develop one. 3. Incorrect: This can best be accomplished by the UAP, it can be done by LPN but not best use of resources. 4. Incorrect: Assessment is a role of the RN. LPN can observe and data collect but not assess and evaluate on the NCLEX. 5. Incorrect: Weighing a client is a task that may be assigned to the UAP.

A client diagnosed with confusion and dehydration is admitted to the medical unit. Which tasks would be best for the RN to assign to the LPN/VN? SATA. 1. Insert an indwelling urinary catheter 2. Reinforce the teaching plan with the client's family 3. Maintain fluids at bedside 4. Assess I & O for adequate fluid replacement 5. Start an IV of normal saline

1. & 2. Correct: The LPN/VN can insert a indwelling urinary catheter since hourly urinary output measurements are needed, this is within the scope of practice. The LPN/VN can reinforce an already prepared teaching plan, but cannot develop one. 3. Incorrect: This can best be accomplished by the UAP, it can be done by LPN/VN but not best use of resources. 4. Incorrect: Assessment is a role of the RN. LPN/VN can observe and data collect but not assess and evaluate on the NCLEX. 5. Incorrect: Starting an IV is not within the universal scope of practice for the LPN/VN. This is an expanded role.

A nurse is observing two unlicensed assistive personnel (UAP) changing sheets for an immobile, obese client. What unacceptable action by the UAPs would require the nurse to intervene? 1. Stands straight with feet together. 2. Asks client to lift head off the bed. 3. Pulls draw sheet with both hands. 4. Faces slightly towards head of bed.

1. Corect: When moving a client, the most important safety action for the staff doing the lifting is to spread their feet apart to shoulder width, with knees slightly bent, to prevent back injury. The feet should never be placed together. The most stable part of the body is at the hips, and moving feet apart stabilizes the lifter. The nurse would intervene in this scenario before the UAPs are injured. 2. Incorrect: The UAPs are aware when sliding a client up in bed, if the client does not lift their head, the sudden movement could hyperextend the client's neck, causing severe trauma. The client must lift head off bed just before the staff moves the draw sheet to prevent neck injury. This is a correct action. 3. Incorrect: When moving an obese client, there should be at least two staff members on each side of the bed, grasping the draw sheet with both hands. With a firm grasp on the draw sheet, the staff then slides the client upward in the bed. The UAPs completed this action correctly. 4. Incorrect: Before moving the client upward, all staff should turn slightly toward the head of the bed, feet planted shoulder width apart and firmly grasp the draw sheet with both hands. This position is correct for both client and staff safety.

Who often performs the responsibilities of a case manager? Select all that apply 1. Physical therapist 2. Social worker 3. Dietitian nutritionist 4. Nurse 5. Unlicensed assistive personnel

2. & 4. Correct: A client's case manager can be a nurse, social worker, or other appropriate professional. Case management is a cross-disciplinary practice. It's function is to advocate for the client. 1. Incorrect: The physical therapist focuses on one area which is the client's ability to move and perform functional activities in their daily lives. The physical therapist would not be the client's case manager. 3. Incorrect: The dietitian nutritionist focuses on one area which is human nutrition and the regulation of diet. The dietitian nutritionist would not be the client's case manager. 5. Incorrect: The unlicensed assistive personnel does not have the education and/or training for case management.

The charge nurse on the pediatric unit has several tasks that need to be completed. What tasks can be assigned to the unlicensed assistive personnel (UAP)? Select all that apply 1. Obtain a urine sample from an infant. 2. Empty a nasogastric (NG) canister for client with ileus. 3. Feed a child with bilateral burns of hands. 4. Change an ostomy appliance on child with stoma. 5. Ambulate an adolescent two days post appendectomy.

3. & 5. CORRECT: A UAP can perform any activities of daily living (ADL), including feeding, transfers in or out of bed and ambulation. Feeding a child whose hands are bandaged is an appropriate task. Also, ambulating the adolescent is definitely within the scope of duties for the UAP. The RN cannot delegate assessment, evaluation, plan of care development, or teaching to an LPN or UAP. When contemplating the options in this question, consider whether the action would require any type of assessment or advanced training in order to complete. 1. INCORRECT: Obtaining a urine sample from an infant is too complex for a UAP. The two methods used for collecting this urine sample is either straight catheterization of the infant or use a "wee bag". Neither of these methods can be performed by a UAP. 2. INCORRECT: Emptying containers can be within the realm of duties for a UAP. However, that does not include a NG canister. A nurse must assess the color, consistency, and amount of drainage in the canister in addition to location and position of the NG tube. This particular action should be completed by a nurse. 4. INCORRECT: Changing an ostomy appliance is a complex task. A nurse needs to assess the skin for evidence of skin breakdown or excoriation that needs treated before another flange is applied. The nurse must also assess the condition of the stoma. This is not a task appropriate for a UAP, although emptying the ostomy bag would be appropriate.

The nurse is planning care for a client admitted with Alzheimer's Disease. What interventions can the nurse delegate to the LPN/VN? Select all that apply 1. Teach caregivers memory enhancement aids. 2. Evaluate client's safety risk factors. 3. Make referrals to community services. 4. Determine caregiver's stress level and coping strategies. 5. Monitor for behavioral changes. 6. Check environment for potential safety hazards.

5. & 6. Correct: The LPN/VN can monitor for behavioral changes and can look for potential safety hazards. Specifically, the LPN should monitor client appearance, mood, and psychomotor behavior and observe for changes. 1. Incorrect: The RN is responsible for teaching. This task cannot be delegated to the LPN/N. The LPN/VN can reinforce teaching. 2. Incorrect: The RN is responsible for assessment and evaluation of clients. The LPN/VN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. 3. Incorrect:The RN is responsible for developing the plan of care which would include necessary referrals. 4. Incorrect: This again is assessment which is the role of the RN only.

A hospital has incorporated new equipment on all units without nursing or staff input. Frustrated staff members approach the nurse manager, requesting a resolution of the situation. What response by the nurse manager would be most appropriate? 1. "You are over-reacting to this new equipment." 2. "Perhaps you just need some further training." 3. "Unexpected changes can be difficult to accept." 4. "If we work together, everything will get better." Hint: The nurse manager's responsibility is to interact therapeutically with those affected by the change. What approach do you think might best help the staff adjust to new equipment which may, or may not, improve client care?

Options that imply everything will be all right, deny clients' feelings, change the subject raised by the client, encourage the client to be cheerful, or transfer nursing responsibility to other members of the healthcare team usually are distractions and can be eliminated from consideration. 3. Correct:The nurse manager should utilize therapeutic techniques with staff as well as clients. The introduction of new equipment, particularly with no staff input, can cause frustration, job dissatisfaction, or even anger. Open-ended statements and questions allow staff to verbalize emotions in a situation which has led to feelings of powerlessness. This approach by the nurse manager will help staff adapt more successfully to this situation. 1. Incorrect: This closed, antagonistic remark is accusatory and provides no opportunity for staff interaction. The nurse manager has responded by placing blame on the staff instead of encouraging the expression of feelings and frustrations. 2. Incorrect: Such a comment focuses on training or lack of staff knowledge regarding the new equipment. This is a closed-ended comment which focuses on the issue of staff learning rather than lack of input for the equipment. 4. Incorrect: Though the comment may seem encouraging, the nurse manager is ignoring the staff's feelings and implying everything will be okay. This belittles staff emotions and is closed-ended, eliminating the opportunity to work through feelings. Therapeutic communication is designed to encourage sharing of feelings in an accepting and nonjudgmental environment. The nurse manager makes reference to working together, which may seem like a good idea, but the statement does not promote further discussion or foster a therapeutic atmosphere.

A cardiac step down unit has requested float staff because of multiple impending admissions. The supervisor can only send one LPN/VN to the floor. Which clients would be appropriate assignments for the LPN/VN? Select all that apply 1. A client with COPD complaining of shortness of breath on exertion. 2. A post-cardiac catherization needing assistance with bedpan. 3. A client receiving heparin injections for deep vein thrombosis. 4. A client with atrial fibrillation currently on a diltiazem drip. 5. A client receiving a blood transfusion that requires monitoring. 6. A client post pacemaker insertion, awaiting discharge instructions. Hint: Remember LPNs can care for stable clients with acute or chronic illnesses. The key is that the client is stable.

Remember: Whenever a nurse is pulled to an unfamiliar unit or a unit where clients have different diagnoses that what that pulled nurse is used to caring for, that nurse should be assigned stable, predictable clients. 1, 3 & 5. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. Client #5 -It is considered within the scope of practice for an LPN/VN to monitor a transfusion of a blood product. 2. Incorrect: This client is post cardiac catherization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. Because positioning on a bedpan requires rolling of the client, an RN should be assigned to assess the insertion site and monitor for the presence of bleeding. 4. Incorrect: Atrial fibrillation places the client at risk for blood clots. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. Assessing this client and titrating the diltiazem requires the skills of an RN. 6. Incorrect: Discharging a client includes teaching and a review of medications to be taken at home. These areas require the expertise of an RN and would not be appropriate for an LPN/VN.

The outpatient surgical unit has admitted multiple clients currently awaiting early morning procedures. What client should the nurse assess first? 1. The client awaiting repair of hiatal hernia reporting chest pain. 2. The client with a torn right rotator cuff reporting shoulder pain. 3. The client with an inguinal hernia repair reporting skin irritation. 4. The client awaiting a hemorrhoidectomy reporting rectal bleeding.

1. Correct: A hiatal hernia occurs when a portion of the stomach pushes up through the esophageal ring (hiatus) of the diaphragm. Surgical intervention is generally a last resort and only when there is evidence of serious complications. Although chest pain could be the result of reflux within the esophagus, it could also indicate a strangulated hiatal hernia. The nurse needs to assess this client immediately. 2. Incorrect: A torn rotator cuff is generally only repaired when other treatment options have been ineffective, such as rest, ice, NSAIDs and even steroid injections. This client has been ordered a surgical repair, indicating other therapies have failed. Shoulder pain on the affected side is to be expected and not an urgent need. 3. Incorrect: An inguinal hernia is the protrusion of intestine through abdominal muscles, creating a painful bulge which worsens with lifting, bending, or straining. Skin irritation usually results from wearing a supportive garment known as a truss. The purpose of this belted device is to apply pressure and provide support to the area of the hernia until surgical repair. Skin irritation is not the nurse's priority. 4. Incorrect: Large or engorged rectal hemorrhoids may require surgical repair because of excessive bleeding, pain, or prolapse. This type of bleeding is not unexpected nor does it present any major concerns about shock. This client would not need to be seen first.

The nurse leader is planning to change the method of client documentation on the unit. Some employees accept the change without difficulty; however, some of the employees are resistant to change and try to sabotage the plans for change. Which action should the nurse leader take to reduce resistance to change on the unit? 1. Allow staff on the unit a voice in the plan for change. 2. Discourage discussion between supporters and resisters. 3. Set an implementation date and begin the new method. 4. Announce that the plan for change is set by administration.

1. Correct: Allowing everyone an opportunity to speak may reveal the reasons behind the resistance. If everyone has a voice, each person is more likely to buy into the new method. This option also is the most positive action to take from the choices available. 2. Incorrect: Supporters and resisters should communicate. Perhaps the supporters can persuade the resisters. Encouraging discussion keeps communication lines open and is more likely to decrease resistance. 3. Incorrect: Setting a date for implementation should come after discussion and training on the new process. A target date must be set; however, the groundwork for change must occur first. 4. Incorrect: Staff is more likely to accept change that affects them if they have a voice. Administration can take staff suggestions and possibly make a better plan.

The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. The nurse has just completed a 12 hour shift. What options would be appropriate for the nurse to take? Select all that apply 1. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action. 5. Simply accept the assignment since overtime is mandatory.

1., 2., 3., & 4. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. Shouldn't the nurse identify whether personal fatigue will be an issue in caring for clients? Splitting the overtime shift is an acceptable option that the nurse could suggest in order to solve the staffing problem and decrease the amount of time the nurse will be working. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. This documentation should go to your manager. Refuse the assignment, being prepared for disciplinary action. If your reasons for refusal were client safety, nurse safety, or an imperative personal commitment, document this carefully including the process you used to inform the facility (nurse manager) of your concerns. Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. 5. Incorrect. The nurse can also accept the assignment; however, that nurse should document professional concern for client safety and the process you used to inform the facility (manager) of your concerns. Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court.

Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Select all that apply 1. Prepare a client's room for return from surgery. 2. Observe for pain relief in a client after receiving acetaminophen with codeine. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogastric (NG) tube. 5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy (PEG).

1., 3, & 4. Correct. These are appropriate tasks for an UAP to complete. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. Also, making a surgical bed for the client returning from surgery is a basic procedure. 2. Incorrect. The UAP cannot assess or evaluate or even monitor the effectiveness of pain medication. That is what you are asking the UAP to do here. The client has received a narcotic and you have asked the UAP to evaluate the effectiveness of the medication. 5. Incorrect. Administering tube feeding into a PEG tube is beyond the scope of practice for the UAP. This is a procedure which requires a licensed personnel. Catheter placement must be confirmed, client identity checked, tube site flushed with water or sterile water and flow rate determined.

Which tasks should the charge nurse complete at the end of the shift before leaving for the day? Select all that apply 1. Listen to the nurses as they share the concerns of their assigned clients. 2. Call the family of a client suffering from dementia to discuss long term care placement. 3. Briefly assess every client. 4. Complete a client assignment sheet for the oncoming staff. 5. Receive report from the emergency department (ED) on a new client.

1., 4., & 5. Correct: Talking to the nurses about client concerns and completing the client assignment sheet for oncoming staff will provide for a thorough shift change report. It is crucial that the oncoming staff have an opportunity to voice any concerns regarding assignments and clarify any information provided. This proper exchange of information and concerns helps to ensure the safety of clients, provides continuity of care, and possibly prevents problems that might arise if these concerns had not been addressed. Taking the report from the ED could be delayed but is a courtesy to the ED and will provide information about the client that will be useful in making assignments for the next shift. 2. Incorrect: This will take some time and would be best accomplished by sitting with the family to discuss options. Doing this at the end of the shift could prevent completion of the client assignment sheet for the next shift and possibly create unnecessary overtime for the charge nurse. 3. Incorrect: Watch out for words like "all", "every", and "never." The charge nurse does not have to assess every client. This will take a lot of time, and the charge nurse can get the information needed from the nurses caring for the clients in order to make appropriate client assignments for the next shift.

The charge nurse is planning the staff assignments for the clients on a neurological unit. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? 1. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. 2. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. 3. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. 4. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96.

2. Correct: The medical nurse can be assigned to this client. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an antiseizure medication. The stem does not indicate any loss of neurological function resulting from the seizure activity. 1. Incorrect: This client is exhibiting early signs of increased intracranial pressure. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. 3. Incorrect: An experienced neurological nurse should be assigned to this client due to the possibility that damage to the hypothalamus which controls body temperature has occurred. An increased temperature will have a direct effect on the brain's metabolism and function. There is a possibility that a hypothermia blanket may be prescribed. 4. Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. An experienced nurse would be assigned to this unstable client due to the possibility of a reoccurring hemorrhagic stroke resulting from the client's hypertension.

A newly hired unlicensed assistive personnel (UAP) at a long-term care facility is being instructed on the proper method of feeding a stroke client with dysphagia. The nurse knows teaching was successful when the UAP makes what statement? 1. "Feeding the client in semi-fowlers position is easier." 2. "I should not allow the client to do any self-feeding." 3. "Thickened liquids are safer for the client to swallow." 4. "I am offering the client a drink after each bite to help digestion."

3. Correct: Thickened liquids allow for easier swallowing and less choking, thus decreasing the chance of aspiration. The client should be sitting upright and fed small amounts of food slowly, allowing time for chewing and swallowing. This statement indicates the UAP understands proper feeding protocols. 1. Incorrect: Semi-fowlers is a "semi-reclining" position, which would greatly increase the risk of aspiration during meals. This comment indicates the UAP would need further instruction. 2. Incorrect: It is crucial to encourage a stroke client to participate as much as possible in self-care, including feeding and bathing. If this client is capable of using utensils, such as modified silverware, it is important to allow as much participation in activities of daily living (ADL) as possible. If the UAP made this comment, further teaching is indicated. 4. Incorrect: Liquids after every bite would quickly fill up the client, decreasing the amount of food intake. Feeding slowly and allowing the client time to swallow after each bite is sufficient for digestion. Such a statement from the UAP means further instruction is needed.

The nurse discovers that a client was given the wrong medication. After verifying the client is stable, an incident report is completed. What is the proper disposition of the report? 1. Send a copy of the report to the primary healthcare provider. 2. Notify the State Board of Nursing about the incident report. 3. Document that a report was completed on the client's chart. 4. Give the report to the hospital's risk management team.

4. Corect: The purpose of an incident report is to describe and document a particular event, injury, medication error, or other occurrence that affects a client or staff member. This report is then sent directly to the hospital risk management team for the express purpose of developing a plan or protocols to prevent a repeat occurrence. 1. Incorrect: Although the primary healthcare provider will need to be informed of the medication error and the client's current status, including vital signs, a copy of the incident report is not provided. 2. Incorrect: The State Board of Nursing is rarely notified about medication errors or the existence of an incident report. 3. Incorrect: The information documented on the main chart includes the client's current status and assessment specifics. It should also be documented that the primary healthcare provider was notified. However, there should not be any mention of the incident report on the client's chart.

The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. The nurse received a client following surgery 8 hours ago. The first vital sign check was performed by the nurse. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. What was the rationale for this plan? 1. The nurse did not trust the new UAP. 2. The nurse prefers to check all vital signs on all clients. 3. The nurse is responsible for the assessment of all vital signs of post-op clients. 4. The nurse does not know the skills of the new UAP.

4. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. When the licensed person cannot determine this, the task should not be delegated. This determination is needed to assure client safety is being considered. 1. Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. 2. Incorrect: When a unit is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. In this situation, it is not a matter of the nurse preferring to take all the vital signs, but the nurse needs to know the competency level of the UAP before delegating this task. 3. Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. If the client is unstable, the nurse would retain the role of measuring the vital signs. Once the client is stable, the UAP could perform this task. However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client.

The triage nurse in the emergency department is prioritizing the client care for new clients. What is the correct order in which the clients should be evaluated? 1. Elderly client rating intermittent substernal chest pain a 4 on a 10-point pain scale. 2. Adult reporting right lower quadrant abdominal pain. 3. Child who has a laceration to the hand with bleeding controlled by pressure. 4. Infant having a tonic-clonic seizure. 5. Teenager with a blood glucose of 108 mg/dL (6 mmol/L). Hint: Ask yourself "Who could die if I do not see them first?"

First the nurse needs to evaluate the infant having a seizure. This client is in acute distress. The infant should be treated first to assess the infant's airway and neurological status. Second would be the elderly client presenting with chest pain who has a pain intensity of 4 on a scale of 10. Chest pain is possible symptom of a lethal cardiac event. At the time of the triage the infant's seizure activity and potential airway obstruction should be attended to first. Third would be the adult client with abdominal pain. The abdomen is painful, but clients with potential life-threatening complications should be evaluated first. Next, the child presenting with a laceration to the hand, should be seen. The bleeding is under control with pressure so can be seen after the other three clients. The teenage client's blood glucose level is with normal limits. The other clients should be attended to first, so this client would be last.

A client diagnosed with pancreatic cancer is being discharged home to live with an adult child. What action should the nurse take to promote continuity of care? 1. Identify community services available for the client and family. 2. Refer client for hospice care. 3. Advise family that client would benefit more from nursing home placement. 4. Make arrangements for around the clock home health aides.

1. Correct: The nurse promotes continuity of care at discharge by providing a smooth transition from one level of care to another. The nurse should include in the discharge plan appropriate community support services available to the client and family so that they can obtain support as needed. 2. Incorrect: This may be premature at this point. Hospice referral is provided when any person with a life threatening illness, which measures life in months rather than years, qualifies for hospice care. 3. Incorrect: It is not appropriate for the nurse to impose personal opinions about what is best for the client. 4. Incorrect: This may be premature at this point. Further assessment is needed and can be provided as the cancer progresses.

Which referral would the nurse anticipate that the primary healthcare provider would make for a client who has difficulty eating using regular utensils? 1. Occupational therapist 2. Physical therapist 3. Rehabilitation nurse 4. Registered Dietitian

1. Correct: An occupational therapist helps physically disabled clients adapt to physical limitations and is most qualified to help clients improve their ability to perform activities of daily living. OT's help clients learn to approach tasks differently, use assistive devices or equipment, make adaptations to the home or work environments and find ways to assist the client in meeting personal goals. 2. Incorrect: The physical therapist is trained to deal with problems that limit their abilities to move, perform daily functions, or remain active and independent. However, physical therapists do not assist with special adaptations needed to perform activities of daily living such as eating. 3. Incorrect: A rehabilitation nurse can help a client eat, but isn't trained in modifying utensils. The rehabilitation nurse assists clients as they adapt to altered lifestyles and assists clients to attain and maintain the highest level of functioning. Some of the aspects included in the role of the rehab nurse includes encouraging self care, preventing complications and further disability, setting goals for independent functioning, and assisting clients to access additional care needed. The rehabilitation nurse would work collaboratively with the occupational therapist (OT). The OT is the one who will best meet the needs of this client who is experiencing difficulty eating with regular utensils. 4. Incorrect: A registered dietitian manages and plans for the nutritional needs of clients but isn't trained in modifying or fitting utensils with assistive devices. This would be the role of the OT.

Which client would be most appropriate for the emergency department charge nurse to obtain a social service consult? 1. Six year old who ingested diluted bleach. 2. Ten year old who suffered burns in a house fire. 3. Twelve year old who fractured his arm in a fight at school. 4. A 16 month old without any oral intake for the last 12 hours.

1. Correct: In most areas, laws mandate certain situations/circumstances involving children be reported to social services/child protection. Among these things are: ingestion of toxic substances, fractures, suspected neglect or abuse, burns. For older children and adults, the healthcare provider uses their judgment as to whether the situation indicates neglect or abuse by the parents or caregivers. 2. Incorrect: The child in a burned house would be reported only if the story were inconsistent as to how the house caught on fire, or if foul play is suspected. 3. Incorrect: A child fighting at school is inappropriate, but this doesn't mean there is family abuse/neglect at home. 4. Incorrect: A 16 month old who is sick may not take liquids, but the fact that the mother brought the child in means she is attentive and concerned. The nurse would determine why the 16 month old is not drinking liquids then rehydrate the child to prevent dehydration.

The home health nurse is concerned about the safety of the client who lives alone in a poorly maintained home. The nurse convenes the interdisciplinary team to discuss the situation. Which action should occur first? 1. Share the assessment findings with the interdisciplinary team. 2. Suggest that the social worker visit the client in the home. 3. Ask the primary healthcare provider about possible nursing home placement. 4. Suggest a "meals on wheels" solution to nutrition.

1. Correct: The assessment findings from the home health nurse will allow each person of the team to offer input based on their particular expertise. After assessment findings have been discussed, the problem solving approach can begin. The interdisciplinary team works together and shares their expertise, knowledge and skills to improve client care. 2. Incorrect: Suggesting a social worker visit may be appropriate; however, this situation would best be served by a discussion with the entire team first. 3. Incorrect: Nursing home placement may be appropriate; however, this is not the first step in collaboration with the team. The team will discuss the home health nurse's concerns and problem solve to provide solutions. 4. Incorrect: Nutrition is a pertinent issue that may need to be addressed; however, the entire team's input is needed at this point. Also the nurse's concern in the safety of the client in a poorly maintained home.

The charge nurse walks into the client's room as the staff nurse is preparing the client for discharge. The charge nurse overhears the staff nurse giving the client her phone number. The staff nurse says, "Call me when you get home, and maybe we can get together sometime." What should the charge nurse do first? 1. Interrupt the staff nurse and complete the discharge. 2. Tell the staff nurse in the client's presence that the action is inappropriate. 3. Make no comment, and let the staff nurse continue to talk with the client. 4. Stay with the client until ready to leave the unit.

1. Correct: The charge nurse should make sure that professional boundaries are maintained; therefore, the charge nurse should interrupt the process and continue with the discharge procedure. Then the nurse should be counseled immediately so that further inappropriate behavior does not occur. 2. Incorrect: The nurse should be counseled; however, counseling does not need to be done in front of the client. The better option is to counsel the staff nurse in private. 3. Incorrect: The charge nurse must make sure that professional boundaries are maintained. To make no comment indicates acceptance of the behavior. 4. Incorrect: No, the charge nurse interrupts the staff nurse and completes the discharge then counsels the staff nurse on professional boundaries.

An experienced RN and LPN are working with a new nurse who has just recently passed the NCLEX. The team is assigned to care for 12 clients on the medical-surgical unit. Which factor is most important for consideration when delegating? 1. Lack of experience of the new nurse. 2. The preferences of the LPN who has experience. 3. RN's desire to avoid confrontation. 4. Assignment of equal number of clients to the RN, LPN and new nurse.

1. Correct: The lack of experience of one of the team members (the new RN) must be considered when delegating for client safety. The new nurse may not have the knowledge, assessment skills, and experience needed to care for clients who are unstable or have complex health issues. 2. Incorrect: Preferences by nurses should not guide delegation decisions. This takes the focus off what is best for the clients and places the focus on the nurse. 3. Incorrect: The possibility for conflict when delegation decisions are made should not influence these decisions which are made in the best interest of the client. 4. Incorrect: Although it seems like the "fair" thing to do by each nurse caring for the same number of clients, the delegation decisions should be based on the experience of the new RN. Client safety could be compromised by assigning the new nurse to clients who are unstable or have complex health issues. Delegation to the LPN must include consideration of the LPN's scope of practice.

Which task would be appropriate for the nurse to assign to an LPN/VN? 1. Changing a colostomy bag. 2. Hanging a new bag of total parenteral nutrition (TPN). 3. Teaching insulin self administration to a diabetic client. 4. Administering IV pain medication to a two day post op client.

1. Correct: The only procedure listed that is within the LPN/VN's practice range is changing the colostomy bag. This is a task that can be delegated to the LPN/VN. 2. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. This is outside the scope of practice for the LPN/VN. Therefore, the RN must perform this task and cannot delegate this to the LPN/VN. 3. Incorrect: Teaching is outside the scope of practice for the LPN/VN. Teaching can be reinforced by the LPNVN, but they cannot perform the initial teaching. Teaching insulin self administration cannot be delegated to the LPN. 4. Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/VN. This should not be delegated to the LPN/VN.

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which group of clients should she assign to the medical surgical nurse? 1. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. 2. C-section planning discharge, post-partal infection, mastectomy. 3. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. 4. 28 week gestation of bed rest, post-partal with HELLP syndrome, breast reconstruction.

1. Correct: This group of clients is primarily med surgical. 2. Incorrect: This group of clients needs specific teaching. 3. Incorrect: This group of clients needs specialized care. 4. Incorrect: No, the monitoring is too specific for the med-surg nurse.

The nurse has been caring for a client who is confused. Upon entering the room, the nurse finds the client on the floor. The side rails are up, there is urine on the floor, and an abrasion was noted on the client's forehead. Which information should the nurse include in the incident report? SATA. 1. Abrasion on the client's forehead. 2. Nurse's perspective as to how the client fell. 3. Client's confused state. 4. Presence of urine on the floor. 5. Side rails were up.

1., 3., 4. & 5. Correct: The following should be included in an incident report regarding a client's fall: how the fall occurred (if observed); where the fall took place; how the nurse was notified of the fall; the environmental condition (wet, dry, any obstruction conditions); presence of fall deterrents (side rails, call lights, night light); client vital signs; nurse's physical findings (confusion, abrasions); presence of family; and if toileting was an issue. 2. Incorrect: Only facts, not opinions should be stated.

Which tasks are most appropriate for the hospice nurse to delegate to an unlicensed assistive personnel (UAP)? Select all that apply 1. Bathe the client. 2. Provide spiritual support 3. Listen to the client reminisce. 4. Administer routine medications. 5. Weigh the client. 6. Take vital signs Hint: Recall the 5 rights of delegation: right task, right person, right circumstance, right directions, and right supervision.

1., 3., 5., & 6. Correct: The UAP can bathe, listen to the client remininsce, weigh, and take the vital signs. These are within the scope of practice of the UAP. These assignments are routine and revolve around activities of daily living. 2. Incorrect: The task of providing spiritual support could best be delegated to the pastor or chaplain. 4. Incorrect: The nurse can not delegate routine medication administration to the UAP. This is not within the UAPs scope of practice. This is an LPN or RN responsibility.

The nurse on an inpatient psychiatric unit has been assigned to care for a group of clients. Which client should receive priority during morning round assessment? 1. 40 year old woman who is being discharged today. 2. 80 year old man with suicidal thinking. 3. 45 year old man who has suicidal thinking. 4. 50 year old woman with history of acute panic attacks.

2. Correct: Elderly males have the highest risk of suicide in the US. This is the client that is priority and should be assessed first. 1. Incorrect: This client normally would require less intense attention. If this client is being discharged today then they are considered stable. 3. Incorrect: This client should be checked frequently; however, another client listed is at higher risk. This client would be assessed second but the elderly male is at a higher risk. 4. Incorrect: Panic attacks are uncomfortable and the nurse should stay with the client; however, there is no reason to think that the client is currently in distress. The client has a history of acute panic attacks. There is no indication that the client is currently experiencing a panic attack.

A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. What is the most appropriate action by the charge nurse? 1. Assign more daily tasks to the UAP. 2. Provide positive feedback to the UAP. 3. Allow the UAP to work without supervision. 4. Teach the UAP to change surgical dressings.

2. Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. A job well done should be acknowledged, since positive feedback leads to more positive outcomes. It is easy for a new employee to feel uncertain about the job or personal productivity; therefore constructive input from the charge nurse would provide encouragement to the UAP. 1. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. It would not be appropriate to overload this new employee with extra work. 3. Incorrect: The scope of practice for the UAP encompasses basic personal care needs, ambulating, and taking vitals; however, the nurse must still verify that all tasks are accomplished in a safe manner. 4. Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. The nurse cannot allow the UAP to perform advanced tasks.

Which tasks should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply 1. Demonstrate post operative exercises. 2. Reposition the transcutaneous electrical nerve stimulation (TENS) unit. 3. Empty the indwelling catheter bag. 4. Assist a client with position change every 2 hours. 5. Apply anti-embolism stockings.

3., 4. & 5. Correct. It is within the role of an UAP to empty the indwelling catheter bag, assist with position change and apply anti-embolism stockings. The nurse should confirm that these tasks have been done, but they are safe to delegate to the UAP. 1. Incorrect. This is a task for the RN and involves teaching and evaluation of effectiveness. 2. Incorrect. The physical therapist is the best team member to manage the TENS unit since this is a pain control device that affects nerves and muscles.

A preschooler has been hospitalized for observation. The unlicensed assistive personnel (UAP) offers to sit with the child and asks the nurse to suggest an appropriate activity. The nurse knows the best activity choice for a preschool child is what? 1. Children's television show 2. Small stacking blocks 3. A checker board game 4. Children's card game

2. Correct: Preschool children, ages 3 to 5, are in the Erikson stage of "initiative versus guilt" where the learning goals involve exploration and manipulation of the environment. Motor skills are developing, and playing is used to increase self-esteem through imagination and creativity. Stacking small blocks to build structures or create creatures is definitely appropriate for this age group and can easily be done on the bedside table. 1. Incorrect: A preschool child may not have the patience to sit through an entire television show. Additionally, this would not address the developmental needs of this age group, which focuses on creative activities such as coloring, painting, playdough, or building blocks. Even hospitalized children must have their developmental needs addressed. Television may appeal more to adolescents. 3. Incorrect: Table games like checkers are more appropriate for school age children, who tend to like group activities, particularly with peers of the same age and sex. Playing checkers is too tedious and inactive for a young preschooler. 4. Incorrect: Card games, even those designed for children, are generally too boring for youngsters. Preschool children prefer activities which require imagination and activity with others. Dressing up in clothing, riding bikes, or other physical games are good for engaging this age group. In the hospital, creativity can be encouraged with drawing, chalk, or playdough.

At a monthly staff meeting in a long-term care facility, the charge nurse requests staff input to create new activities for the clients. An RN has been assigned to gather information for staff consideration. What method would provide the RN with the best data for this project? 1. Ask clients' families which activities they would like to have available. 2. Research professional articles for guidelines to activities in long-term care. 3. Have clients peruse a variety of games and select what interests them. 4. Contact other facilities to inquire what types of programs they provide.

2. Correct: Research based criteria generally have a high rate of success because the testing has been completed under controlled circumstances and are practice based. 1. Incorrect: Although it would be acceptable to speak with the clients' families, this would not provide the most complete data for the project. Families would not likely understand pertinent considerations such as cost of supplies, number of staff required to assist, or clients' ability to participate. 3. Incorrect: While encouraging client input does allow for some independence, multiple choices can be overwhelming for elderly clients. There would also be an unnecessary expense in purchasing and providing multiple choices for the clients. 4. Incorrect: Most facilities individualize activities based on clientele, funding, and even location. Activities that work in one long term care facilities may not be appropriate for another facility.

What task can the nurse assign to an unlicensed assistive personnel (UAP) while caring for a client diagnosed with a stroke? Select all that apply 1. Check the client's gag reflex. 2. Assist with feeding the client. 3. Monitor the client's headache pain level. 4. Encourage client to expression frustrations. 5. Maintain the head of the bed at 25 - 30 degrees.

2., & 5. Correct: It is within the scope of practice for an UAP to maintain a designated bed position and assist with feeding a client. The nurse is responsible for setting the bed at the prescribed position and will direct the UAP to maintain this bed position. The UAP is also trained to assist clients with feeding. 1. Incorrect: Assessing the client's gag reflex is not within the scope of an UAP. A nurse would need to be trained in specific techniques to assess the client's gag reflex. 3. Incorrect: It is not within the scope of a UAP to assess the pain level of the client. The nurse must assess the location and intensity of the headache. The nurse cannot delegate assessing a client to a UAP. 4. Incorrect: The client should be encouraged to express their feelings, concerns, and needs, but he UAP is not trained in therapeutic communication and other medical and psychological client needs. Encouraging the client to express their frustrations is not within the UAP's scope of practice.

As a member of the emergency preparedness planning team at the hospital, which actions should the nurse encourage the team to implement? Select all that apply 1. Developing a response plan for every potential disaster. 2. Providing education to employees on the response plan. 3. Practicing the response plan on a regular basis. 4. Evaluating the hospital's level of preparedness. 5. Assigning all client care duties to the Nursing Supervisor.

2., 3. & 4. Correct: Developing a single response plan, educating individuals to the specifics of the response plan, and practicing the plan and evaluating the facility's level of preparedness are effective means of implementing emergency preparedness. The basic principles of emergency preparedness are the same for all types of disasters. Only the response interventions vary to address the specific needs of the situation. 1. Incorrect: One good response plan, not multiple plans, should be developed. This will ensure adequate understanding of the plan and decrease confusion of roles that could occur with multiple plans. Different types of disasters have been identified such as natural disasters, severe weather, recent outbreaks, radiation emergencies, chemical emergencies, and bioterrorism. There is no feasible way for the hospital to have a response plan for every potential disaster. The overall disaster plan can be modified for specific intervention for different types of disasters. 5. Incorrect: All client care duties cannot safely be assigned to one caregiver. The nursing supervisor needs the help of other staff to carry out nursing care for the clients in the hospital.

The nurse manager is developing a new yearly evaluation form for the staff. What statement(s) by the nurse manager would most likely improve staff outcomes? Select all that apply 1. "How often do you need help to finish assignments?" 2. "Are there any new skills you feel capable to learn?" 3. "Describe how you organize your daily assignments." 4. "Which tasks are most difficult for you to complete?" 5. "Explain any new goals you would like to achieve."

3 & 5. Correct: Positive outcomes are more likely when staff feels appreciated, receiving constructive and encouraging feedback on a regular basis. Evaluations can be very stressful when staff are uncertain of expectations or are perceived in a negative framework. Seeking clarification on how staff organize assignments indicates awareness and may help in developing new protocols. Also, showing interest in individual goals will help develop learning opportunities for all staff. 1. Incorrect The tone of this question is derogatory, implying the individual is not able to complete daily assignments in a timely manner without assistance. 2. Incorrect: This inquiry is worded in a negative manner, implying the individual may not have the ability to learn new skills. 4. Incorrect: Although this might present information the nurse manager might use to develop more learning opportunities, the negative approach may intimidate staff, preventing complete honesty. All facilities provide periodic evaluations of staff to improve performance and enhance productivity. Many staff personnel dread these evaluations which often focus on negative issues that point out only personal short-comings. However, a well worded evaluation can help an employee improve skills while providing positive feedback and encouragement. Did you also notice that among the options for the new staff evaluation form, several areas are close-ended while others are open-ended statements? Therapeutic techniques should always be worded in such a way that allows or encourages a client to verbalize feelings. This brings up another issue. Who is the actual client in this question? The client is the staff for whom the nurse manager is developing a new evaluation form! Therefore, the wording on that form should be professional, positive, and open-ended in order to obtain accurate information.

When making assignments for an LPN on the Labor and Delivery unit, the charge nurse is aware the most appropriate clients should meet what criteria? 1. Clients requiring close monitoring. 2. Post-vaginal delivery clients only. 3. Clients with a predictable outcome. 4. Non-routine clients in early labor.

3. Correct: A client with a predictable outcome is stable enough to be assigned to the licensed practical nurse (LPN). If complications should arise, the LPN would report this to the registered nurse. 1. Incorrect: Clients requiring close monitoring indicate an unstable or unpredictable status, which is not an appropriate assignment for the LPN. These clients should be assigned to a registered nurse. 2. Incorrect: The manner of delivery a client experienced does not dictate which staff personnel are able to provide care. More important factors would focus on whether the client had a non-eventful delivery or suffered any unexpected complications. 4. Incorrect: The term "non-routine" immediately indicates an unstable client with potential problems that need frequent assessment. An LPN should only be assigned to those stable clients with expected or predictable outcomes.

A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. The nurse considers various ideas submitted by team members. What proposal would the nurse determine to best meet the needs of families and clients in long term care? 1. Plan all care to be completed in early morning to allow afternoon for visitation. 2. Schedule visiting times in two-hour increments so clients are not overwhelmed. 3. Encourage clients and families to develop mutually appropriate visitation times. 4. Allow families unlimited visitation around the clock to meet their schedules.

3. Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. Because facilities generally prefer some type of consistent schedule for staffing purposes, older visitation policies were often very restrictive. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. 1. Incorrect: This is not completely practical for everyone. Though it may benefit staff to have one particular goal, some clients cannot tolerate to have everything performed at one time, and instead need short rest periods during personal care. This schedule may leave some clients too exhausted to visit with family. 2. Incorrect: Restricting visitation to two hours is not appropriate, particularly for families traveling long distances to visit a client. Those residing in long term care facilities benefit greatly from time spent with family or even older friends. A two-hour limit on visits discourages quality time. 4. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility.

An LPN/VN has been floated to the emergency room following a chemical plant explosion. What task would be best to assign to the LPN/VN? 1. Identify and assess each incoming client. 2. Triage and assign color-coded tags to each client. 3. Gather and apply dressings to open wounds. 4. Initiate oxygen and IV lines as needed.

3. Correct: An LPN/VN's scope of practice includes tasks such as wound care. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. 1. Incorrect: Although it will be crucial to identify each incoming client, the LPN/VN's scope of practice does not include assessment. That task would require an RN or primary healthcare provider. 2. Incorrect: In a mass casualty situation, triage allows the nurse or primary healthcare provider to quickly determine which clients are critical versus those stable enough to wait. Because this involves assessment, an LPN/VN would not be assigned this task. 4. Incorrect: Initiating intravenous lines is not within the scope of the LPN/VN. Additionally, the decision to apply oxygen involves assessment of the respiratory system, which also is not within the LPN/VN's scope of practice.

The nurse is evaluating the outcomes of nursing interventions for the client on the long-term care unit. The nurse has determined that the goal was partially met. What should the first nursing action be at this point to maintain quality of care? 1. Identify a new goal for the client since this one has not been achieved. 2. Consider new nursing interventions for achievement of the goal if the condition still warrants it. 3. Determine that the nursing interventions were performed as planned. 4. Allow more time for achievement of the goal.

3. Correct: First, the nurse will want to determine that the interventions were performed. If they were not carried out, the goal could not be achieved. In addition, the nurse should determine if the nursing interventions were carried out appropriately and completely. Evaluation of the effectiveness of the nursing interventions would follow. 1. Incorrect: New goals may need to be identified; however, in this case it is not yet known if the interventions were carried out appropriately. Until it is determined that the current nursing interventions were implemented and performed appropriately, there is no way to accurately explore if new goals are needed. The original goals may be the most appropriate for the client. 2. Incorrect: New interventions may be appropriate, but until the nurse determines if these were carried out appropriately, it would be premature to establish new nursing interventions. 4. Incorrect: Additional time for goal attainment may be appropriate; however, other actions should be performed first. Before extending time for achieving the goal, the nurse should determine if the nursing interventions have been carried out appropriately. If these have been performed, extending the time for goal attainment may delay making changes that are needed.

After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. The RN requests reassigning at least one of the clients to another nurse. What is the best response by the charge nurse? 1. Offer to take one of the clients. 2. Notify the nursing supervisor of the situation. 3. Ask the RN why the assignment is too heavy. 4. Explain to the RN that all the nurses have the same number of clients.

3. Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. The charge nurse needs additional information to make a decision. This will allow the charge nurse to analyze the situation to make a better decision as to whether the assignment should be changed. 1. Incorrect: Volunteering to take a client would add more work to the charge nurse when this might not be necessary. The charge nurse's best response is to first obtain the needed information to make the best decision. 2. Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. The situation should be explored before bringing the supervisor in on the situation. 4. Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. Something new could have occurred with the clients, making the assignments too heavy. The charge nurse might not have realized all the responsibilities of taking this team of clients. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients.

The nurse manager is presenting a seminar on HIPAA regulations to a group of newly hired graduates. When discussing the most common cause of violating client privacy, the nurse knows teaching was successful when the graduates select what situation? 1. Failure to cover client fully during a bed bath. 2. Leaving chart open in full view when at the desk. 3. Discussing client with staff not providing direct care. 4. Healthcare provider not pulling curtain to talk to client.

3. Correct: The most common violation of HIPAA privacy regulations occurs when healthcare workers discuss a client with those not directly involved in the care of the client, including other staff members. Staff may be sitting in the cafeteria or dining area, discussing shift assignments, when overheard by individuals not involved with that client's care. It occurs more than any other type of violation because staff can forget to be aware of the surroundings. Sometimes a nurse is sharing concerns or frustrations, perhaps seeking a sense of comradery with other nurses, but forgetting the issue of privacy. Even if nurses work on the same unit, only those staff members who actually provide direct care to a specific client are permitted access to that client's medical information.Those working in a facility are not entitled to have access to client health data unless providing direct care to that client. 1. Incorrect: Exposing more of the client than necessary during a bed bath is definitely considered a violation of privacy, but necessarily a HIPPA one. 2. Incorrect: Leaving a client's chart open in full view of staff and visitors does violate a client's privacy but, is not as common as another choice. 4. Incorrect: The problem of overhearing conversations may occur in facilities where multiple clients share the same room or in an emergency room where only a curtain exists between clients. Pulling the curtain does not guarantee that voices will not carry, though most primary healthcare providers try keep voice levels at a minimum.

A charge nurse is caring for clients when a new admit arrives on the unit. What action by the charge nurse is most appropriate? 1. Instruct the unlicensed assistive personnel (UAP) to complete emptying the catheter bag, and assess the new admission. 2. Send the UAP to take VS on the new admit and begin the history until she can get there. 3. Assign a nurse on the floor to initiate the assessment process. 4. Ask the unit secretary to make the client and family comfortable until she can complete her present task.

3. Correct: The nurse is the only one who can assess. 1. Incorrect: The UAP can empty the urinary catheter bag, but can not assess the client. 2. Incorrect: It is out of the scope of practice for a UAP to complete any portion of the admission assessment. 4. Incorrect: The unit secretary can welcome the client, but the admission assessment must be completed by an RN.

The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. In order to reorganize staffing, the nurse manager should initiate which action first? 1. Announce the new changes at the monthly staff meeting. 2. Ask for any staff objections to rearranging work hours. 3. Invite staff to contribute ideas on scheduling changes. 4. Explain administration is demanding a decreased overtime.

3. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. One important aspect is encouraging the flow of ideas between management and staff members. Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. 1. Incorrect: While it is true that the nurse manager is ultimately responsible for implementing and announcing new schedule changes, doing so without any staff input can create discontent in the work environment. When staff do not feel vested in any new process, there is a sense of underappreciation. This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. 2. Incorrect: Although this action appears to be opening lines of communication, the nurse manager is actually fostering animosity in a situation where the outcome is already pre-determined. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. 4. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. Assigning blame for the changes to administration will not help staff adjust.

A medical-surgical LPN has been sent to a short-staffed pediatric unit. The charge nurse knows what client would be most appropriate for this LPN? 1. 3 month old child with nonorganic failure to thrive. 2. 14 year old with exacerbation of cystic fibrosis. 3. 5 year old newly admitted with epiglottitis. 4. 10 year old with type 1 diabetes mellitus.

4. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. 1. Incorrect: This client is only 3 months old, which would require specialized skills to evaluate developmental needs. Additionally, nonorganic failure to thrive is a serious situation in which the infant is not getting appropriate nutrition. There could be economic factors, resulting in a lack of food or poor-quality breast milk. Parental beliefs or negligence could also contribute to the situation; therefore, an RN should be assigned to this infant. 2. Incorrect: Although this client is an adolescent, an exacerbation of cystic fibrosis would require careful and frequent respiratory assessments with possible chest physiotherapy. This client would be more appropriate for an RN. 3. Incorrect: A new admission is not appropriate for a nurse sent from the medical surgical unit to the pediatric unit, particularly an LPN, because of the need for initial and frequent assessments. Epiglottitis is a respiratory illness that also impacts the airway. This child should be assigned to an RN.

During morning report, the nurse learns that a client's call bell is not working and maintenance cannot do repairs until tomorrow. The nurse is aware that the safest temporary method for the client to signal staff is what? 1. Provide a hand-held bell for client to ring. 2. Ask family to stay with client to alert staff. 3. Tell client to call out loudly to the staff. 4. Have staff visit client's room every 15 minutes.

4. Correct: It is vital for clients to be able to contact or alert staff for needs and concerns. The safest method is for the staff to check on the client at specified intervals. This will help alleviate client concerns about being able to signal the staff while ensuring that someone actually observes the client. 1. Incorrect: While a hand-held bell could be an option, it is not reliable. The client could easily push it onto the floor, or it could become tangled in the linens. Additionally, depending on the noise level of the unit, a hand bell could either disturb other clients or not be heard by staff. Waking in the middle of the night can confuse clients, and the use of the hand bell may be forgotten. 2. Incorect: It is not the responsibility of the family to sit with the client 24/7 just because the hospital has non-working equipment. Not only would this be an imposition, it violates most visiting policies and places the burden on the family. 3. Incorrect: Having a client call out to staff is both inefficient and unsafe. Assuming the client's voice is even loud enough to be heard, it is unlikely that the verbalizations of one client could be distinguished from others that may call out because of dementia or normal nighttime utterances. This is not safe.

A nurse has arrived late to work twice in the last week. What should be the nurse manager's first action? 1. Confront the nurse with the consequences of tardiness. 2. Ask the nurse to consent to a drug screening test. 3. Document the tardiness in the nurse's record. 4. Ask the nurse the reason for being tardy.

4. Correct: The first action should be discussing the tardiness with the nurse. There may be a situation that is impacting the nurse's ability to be on time. This will allow the nurse to explain the tardiness. The nurse manager may have to consider alternate scheduling for the nurse. 1. Incorrect: The first action should not be confrontational. The nurse manager needs to find out the reason for tardiness in a non-confrontational manner. This will demonstrate that the nurse manager is showing concern for the nurse. 2. Incorrect: The nurse is not exhibiting any impairment behaviors. Although drug use may be characterized by behaviors such as tardiness to work, this should not automatically be assumed. The nurse should have the opportunity to first provide an explanation for the tardiness. 3. Incorrect: Documentation should be done after the meeting with the nurse. The documentation would include the nurse's explanation for the tardiness.

While a nurse was in shift report, four clients called the nurses' station. Which client should the nurse see first? 1. Child whose colostomy bag is leaking. 2. Three day post op client requesting pain medication. 3. Child admitted with failure to thrive, whose mother requested formula. 4. Client who needs a peak blood level drawn because the antibiotic just finished infusing.

4. Correct: The most urgent task is the peak medication level that needs to be drawn. If the level is not drawn at the appropriate time, the results may not give an accurate report of whether the medication is at the appropriate dosage or not, and if the dosage is safe. 1. Incorrect: A leaking colostomy bag is uncomfortable and should be seen, but this is not time sensitive like the peak blood level. 2. Incorrect: Pain needs assessing and treated appropriately. The key here is three days post op so the administration of the pain medication does not take priority over the need to draw the blood levels at this time. 3. Incorrect: Nutrition for a baby that is admitted for failure to thrive is important, but can wait a few minutes until blood levels are drawn.

Which task would be appropriate for the charge nurse to assign to a LPN/VN? 1. Assessing a client who was just admitted to the unit. 2. Administering morphine IV push to a two day post-op client. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a PICC line that a client accidentally pulled out.

Remember: The RN cannot delegate assessment, evaluation, plan of care development or teaching to an LPN or UAP. 3. Correct: Bolus feeding by way of a gastrostomy tube would be the best assignment for the LPN/VN. This is a nursing action that can be performed by the LPN/VN and does not require verification nor a co-signature by the RN. 1. Incorrect: The LPN/VN can collect data on a new client, but the RN must verify the information and co-sign the assessment. New admits require initial observation and data collection. From this, the RN must evaluate the information and formulate priorities of care. 2. Incorrect: Administering morphine IVP is out of the scope of practice for the LPN/VN. Therefore, this task should not be assigned to the LPN/VN. 4. Incorrect: Reinserting a PICC line is out of the realm of practice for an LPN/VN. Therefore, this task should not be assigned to the LPN/VN.

Patient A and Patient B share a hospital room. Patient B overhears the primary healthcare provider discussing Patient A's laboratory results, including a positive HIV test. Patient B requests to be moved immediately to another room. In what priority order should the nurse complete these tasks? Contact social services to address Patient A's future needs. Notify nurse manager regarding a breach in confidentiality. Educate Patient B about the transmission of HIV and AIDS. Transfer Patient B to another location as soon as available. Encourage Patient A to verbalize feelings regarding the new diagnosis.

The first action by the nurse is to address Patient B's concerns and fears about contracting HIV by presenting information regarding disease transmission. Next, since this situation represents a definite breach of confidentiality, it must then be reported to the nurse manager. Third, despite educating Patient B on modes of transmission, the nurse should attempt to honor their request to be moved to another room. Fourth, address Patient A's needs, by encouraging them to express feelings about their diagnosis and current situation. Additionally, Patient A will have other needs related to the diagnosis which can best be handled by the social services department.

An unlicensed assistive personal (UAP) has been floated to the emergency department (ED) because of several staff call offs. Since the UAP has never worked in the ED, what is the most appropriate task the charge nurse could assign? 1. Clean and restock exam rooms after client discharge. 2. Follow another UAP who has worked there previously. 3. Sit at the reception desk and answer incoming calls. 4. Escort clients from the ED to other areas for tests.

This is tricky, since the emergency room is a specialized area that entails a lot of unique situations and circumstances. You have a spare pair of hands but don't have the time to provide training and orientation - what do you do? 4. Correct: Clients seen in the emergency room are often taken to other hospital departments for tests such as x-rays, CT scans or MRI's. If ordered to another department for testing, such clients are generally stable and could therefore be transported by the UAP. 1. Incorrect: Having never worked the emergency department before, this UAP would not be aware of even basic exam room requirements, particularly involving specialized equipment. Because supplies must be readily available in critical situations, personnel familiar with those requirements and provisions needed for each room should complete restocking of the rooms. 2. Incorrect: A thorough orientation for this UAP would be ideal, especially if there is a chance of being floated to the emergency room again. However, doing so during a staffing crisis is neither appropriate nor efficient, since the UAP is being utilized out of a desperate need for adequate staffing. 3. Incorrect: The reception area personnel are the first staff that encounter incoming clients. This position usually requires some type of training with interviewing techniques or how to determine an acute situation requiring immediate triage. Even answering the phone would involve understanding the necessary prerequisites for that position. This is not an appropriate task for the UAP.

The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Which client should the nurse assess first? 1. Lumbar puncture reporting a headache. 2. Cystogram reporting burning on urination. 3. Thoracentesis reporting shortness of breath. 4. Cardiac catherization with a decreased pedal pulse below insertion site.

When considering complications, always keep the A-B-C's in mind - airway, breathing, circulation! 3. Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. This client should report an improved respiratory, not shortness of breath. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. 1. Incorrect: A lumbar puncture involves removing cerebral spinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. 2. Incorrect: The purpose of a cystogram is to examine the inside of the bladder to confirm the presence or absence of abnormalities, or even obtain a biopsy. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Although this will require assessment, this client is not the priority at this time. 4. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catherization. This invasive procedure results in some edema to the vessel used for the procedure but assessing only one pedal pulse does not provide sufficient data to verify a complication.