Module 5: Principles of Delegation and Prioritization of Care

A registered nurse (RN) is planning client assignments for the day. Which of the following clients should the RN assign to the nursing assistant?

A client who needs frequent ambulation with a walker

A nurse is preparing to administer medications to a client by way of a nasogastric (NG) tube. Before administering the medication, the nurse must first:

Check the placement of the tube

A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first?

Realigning the client

A client with terminal cancer is receiving a continuous intravenous infusion of morphine sulfate. On assessment of the client, what does the nurse check first?

Respiratory status

A nurse manager asks a nurse to work overtime because of a short-staffing problem. The nurse has made plans to do her Christmas shopping after work and does not want to work overtime. What is the most assertive response by the nurse to her nurse manager?

"I have plans after work and will not be able to work overtime."

A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which of the following actions reflects the use of evidence-based practice in the care of the client?

Keeping the door to the client's room closed

A nurse enters a client's room to administer a medication that has been prescribed by the physician. The client asks the nurse about the medication. Which response by the nurse is appropriate?

"It's called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in your diet."

A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding?

"The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge."

A nurse is taking a morning break with the unit secretary in the nurses' lounge. The unit secretary says to the nurse, "I read in Mr. Gage's medical record that he has gonorrhea." How should the nurse respond to the secretary?

"We can't discuss a client's medical condition."

A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability? Select all that apply.

"You are responsible for your own actions." "It carries legal implications for task performance." "You must answer for the care that you ask others to complete." "It refers to the process of answering or being responsible for what occurs."

A case manager is reviewing notations made in clients' records. Which note indicates an unexpected outcome and the need for immediate follow-up?

A client exhibits signs of increased intracranial pressure after a craniotomy.

A registered nurse (RN) who has a licensed practical nurse (LPN) and a nursing assistant on the nursing team is planning client assignments for the day. Which of the following clients should the RN assign to the LPN?

A client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments

A nurse working the 7 am-to-3 pm shift is reviewing the records of her assigned clients. Which client should the nurse assess first?

A client scheduled for hemodialysis at 10 am

A registered nurse (RN) has received the assignment for the day shift. Once the RN has made initial rounds and checked all of the assigned clients, which client will she plan to care for first?

A client who is scheduled for surgery at 1 pm

A nurse is preparing the client assignments for the day. One of the registered nurses on the team has just learned that she is pregnant. Which client does the nurse refrain from assigning to the pregnant team member?

A client with a solid sealed cervical radiation implant

A nurse is assigned to care for four clients. Which client should the nurse assess first?

A client with a tracheostomy who is receiving humidified oxygen by way of a tracheostomy mask

A nurse is planning the client assignments for the shift. Which client should the nurse assign to the nursing assistant?

A client with diarrhea on whom contact precautions have been imposed

A nurse manager is planning client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant (unlicensed assistive personnel)?

A client with renal calculi whose urine must be strained

A nurse, newly employed by a home health agency, is told that the organization's decision-making process is centralized. The nurse determines that this means that the authority to make decisions is vested in:

A few individuals, such as the board of directors

A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the nurse should:

Administer cardiopulmonary resuscitation (CPR)

A registered nurse is in charge of the emergency department (ED) during the night shift. A client arrives at the ED for treatment after a sexual assault. The nurse has never cared for anyone who has been raped. To determine the necessary actions in regard to this client's injury, the nurse should:

Check the unit policy for the protocol for the care of clients who have been sexually assaulted

A case manager is reviewing progress notes in a client's medical record. Which notation indicates the need for follow-up?

Client 2 Heart Failure Crackles were heard in the lower lung lobes bilaterally on auscultation.

A nurse manager arrives at work and is immediately faced with several activities that require his attention. Which activity will the nurse manager attend to first?

Client assignments for the day

A nursing staff member approaches a nurse manager and announces that another nurse is not using alcohol swabs to clean the intravenous port when administering intravenous push medications. What is the appropriate way for the nurse manager to handle this situation?

Reviewing the skills checklist of the nurse who is not using aseptic technique to determine whether the nurse has ever performed this skill and had her technique validated

A charge nurse on the 11 pm-to-7 am shift is gathering the nursing staff together to listen to the 3-to-11 pm intershift report. The charge nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol intoxication. The charge nurse would most appropriately:

Send the staff member home

A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client's wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife?

She will have to discuss the prescribed test with the client.

A 17-year-old client arrives at the clinic and asks to be examined because she believes that she has contracted a sexually transmitted infection. In regard to informed consent, the nurse tells the client that:

She will need to sign an informed consent form

A registered nurse (RN) is supervising a nursing assistant ambulating a client with right-sided weakness. The RN would conclude that the nursing assistant is performing the procedure incorrectly after observing that the nursing assistant:

Stands behind the client

A registered nurse (RN) must determine how best to assign co-workers (another RN and one licensed practical nurse [LPN]) to provide care to a group of clients. Which of the following is the best assignment?

The RN is assigned to care for a woman with newly diagnosed leukemia who has a newborn at home.

A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record reflects the correct use of guidelines for documentation?

The client's intake was 360 mL

Which action by the nurse represents the ethical principle of beneficence?

The nurse administers an immunization to a child even though it may cause discomfort.

A nurse has delegated several nursing tasks to staff members. The nurse's primary responsibility after delegation of the tasks is:

Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task.

A nurse manager discusses staff empowerment with the nursing team. The nurse manager explains that staff empowerment:

Fosters the growth of others so that they are less dependent on the leader

A registered nurse (RN) is planning client assignments for the day. Which clients should the nurse assign to a nursing assistant (unlicensed assistive personnel)? Select all that apply.

A client who requires transport to the radiology department in a wheelchair A client with a Foley catheter for whom a 24-hour urine collection is in progress

A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client's record indicate an unexpected outcome and the need for follow-up? Select all that apply.

A client with a central venous catheter has a temperature of 100.6° F.

A nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client's lung has reexpanded and notifies the physician. The physician verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to asks that the chest tube be removed. The nurse should first:

Inform the physician that removal of a chest tube is not a nursing procedure

The nurse reviewing a client's record sees that the following medications are prescribed. Which medication should the nurse plan to administer first?

Levothyroxine (Synthroid) 137mg orally

A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing?

Nonmaleficence

A nurse planning care for her assigned clients understands that the purpose of the hospital's standards of care is to:

Provide direction for the practice of nursing

A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig's disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-not-resuscitate (DNR) order. The nurse should tell the client that:

The DNR request should be discussed with the physician, who will write the order

A nurse is assisting a physician in assessing a hospitalized client. During the assessment, the physician is paged to report to the recovery room. The physician leaves the client's bedside after giving the nurse a verbal prescription to change the solution and rate of the intravenous (IV) fluid being administered. What is the appropriate nursing action in this situation?

Asking the physician to write the prescription in the client's record before leaving the nursing unit

A nurse is planning client assignments for the day. Which of the following assignments is the least appropriate for the nursing assistant?

Assisting a client with dysphagia in eating

A nurse preparing a client to go to the radiology department for a chest x-ray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take?

Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms

A man who is visiting his wife in a long-term care facility for people with Alzheimer's disease collapses and is transported to a hospital. The client remains unconscious, and testing reveals that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the wife's care facility report to the hospital physician that the client has no other family members and that his wife is mentally incompetent. What information regarding do-not-resuscitate (DNR) orders does the nurse remember?

That a DNR order may be written by a client's physician

A client asks a nurse about the procedure for becoming an organ donor. The nurse tells the client:

That anatomical gifts must be made in writing and signed by the client

A client admitted to the hospital has a do-not-resuscitate (DNR) order in his medical record. The nurse understands that:

The DNR order requires frequent review as specified by state or agency policy

A nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, "The medication is needed to prevent the spread of infection, and if you don't take it orally I will have to give it to you in an intramuscular injection." Which of the following statements accurately describes the nurse's response to the client?

The nurse could be charged with assault.

An 18-year-old client is brought to the emergency department (ED) by emergency medical services after sustaining life-threatening injuries in an automobile accident. The client is unconscious and requires an emergency splenectomy. A nurse in the ED assists in quickly preparing the client for surgery and tries to contact the client's parents but is unsuccessful. In regard to informed consent for the surgery:

The nurse understands that consent is not needed

A nurse employed in a community hospital as a nurse manager understands that in this position, the term authority most appropriately refers to:

The official power to see that an organizational decision is enforced

A nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client's necklace?

Ask the client for permission to lock the necklace in the hospital safe

A nurse educator describes the standards of care formulated by the American Nurses Association to a group of new nursing graduates hired by the hospital. Which of the following options are accurate descriptions of these standards of care? Select all that apply.

Define professional practice Have some similarity to policies and procedures Are authoritative statements that describe a common or acceptable level of client care or performance

A nurse leader in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is "uncooperative and a real pain to care for." The nurse leader would most appropriately manage this issue by:

Discouraging the judgmental comments

A registered nurse (RN) is planning assignments for five clients on the nursing unit. The team includes a licensed practical nurse (LPN) and a nursing assistant. Which clients should the nurse assign to the LPN? Select all that apply.

A client with a colostomy who requires reinforcement regarding the procedure for irrigation A client with diabetes mellitus who requires the administration of regular insulin in accordance with a sliding dosage scale every 4 hours

A registered nurse (RN) is watching as a new licensed practical nurse (LPN) administer an intramuscular (IM) injection in a client's deltoid muscle. The RN determines that the LPN is performing the procedure correctly if the LPN:

Administers the injection 2 inches below the acromion process

The nurse is preparing client assignments for the day. Which client should the nurse assign to a nursing assistant?

An unconscious client who requires oral care

A nurse who works in a medical care unit is told that she must float to the intensive care unit because of a short-staffing problem on that unit. The nurse reports to the unit and is assigned to three clients. The nurse is angry with the assignment because she believes that the assignment is more difficult than the assignment delegated to other nurses on the unit and because the intensive care unit nurses are each assigned only one client. The nurse should most appropriately:

Ask the nurse manager of the intensive care unit to discuss the assignment

A nurse sees another nurse changing an intravenous (IV) solution because the wrong solution is infusing into the client. The nurse who changed the IV solution does not report the error. What should the nurse who observed the error do first?

Ask the nurse whether she intends to report the error

A nurse is reading the nurse practice act for the state in which she is employed. The nurse uses the information in this act to:

Be aware of the role of the professional nurse

A nurse employed at a hospital is asked by a nurse manager to review the organizational chart. The nurse reviews the chart so that he will:

Be familiar with the organization's line of authority

A nurse calls a physician to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The physician, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration. What is the appropriate action on the part of the nurse?

Calling the physician who gave the telephone prescription to clarify the prescription

A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client's advocate by:

Calling the surgeon and asking that the risks be explained to the client

A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. The nurse should first:

Check the client's level of consciousness and vital signs

A nurse is providing a change-of-shift report on his assigned clients, using an audiotape. Which of the following pieces of information should the nurse include in the report about each assigned client? Select all that apply.

Client needs and priorities of care Current diagnosis and any secondary diagnoses Results of laboratory studies conducted that day Client response to treatments implemented that day

A case manager is serving on a community task force on violence in schools. The members of the task force are planning to develop interventions to help prevent violence. According to the nursing process, the first activity that the nurse would suggest to the task force is:

Conducting a community survey to assess community perceptions regarding school violence

A registered nurse (RN) in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take her break. To ensure client safety during her break, which of the following actions should the nurse take? Select all that apply.

Conducting client rounds before taking the break Taking the break in the staff lounge located on the nursing unit

A nurse manager has announced a change to computerized documentation of nursing care. A licensed practical nurse (LPN) on the team, resistant to the change, is not taking an active part in facilitating implementation of the new procedure. Which of the following strategies would be the best approach to dealing with the conflict?

Confronting the LPN and encouraging him to express his feelings regarding the change

A nurse manager tells the nursing staff that they will need to comply with the mandatory overtime policy that the hospital has implemented. Later that day, the nurse manager overhears a nurse complaining about the policy and telling other nurses that she will not work the overtime if she has made other plans after her regular shift. What is the best approach for the nurse manager to use in dealing with the conflict?

Confronting the nurse regarding her behavior regarding the overtime policy

A nurse who has been employed in a hospital for 8 weeks is consistently taking extended lunch breaks. The nurse's behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse manager to deal with this situation?

Confronting the nurse to discuss the behavior and initiate problem-solving measures

A physician writes a medication prescription in a client's record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the physician, who states that this is the dose that the client takes at home and that it is acceptable for this client's condition. What is the appropriate action for the nurse to take?

Contacting the nursing supervisor

A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion, compared with active motion, of the left arm. On the basis of these assessment findings, which action should the nurse take first?

Contacting the physician

The nurse notes that a physician has documented the following prescription in a client's record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take?

Contacting the physician

In which situation is the nurse upholding the ethical principle of fidelity?

Contacting the physician about the client's request to incorporate complementary therapies for pain into the treatment plan

A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she has does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse?

Contacting the surgeon and requesting that she visit the client to answer her questions

A physician repeatedly asks a nurse to write his verbal prescriptions in his clients' charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and explains this to the physician, but the physician tells the nurse that she will be reported if she does not write the prescriptions. How should the nurse manage this conflict?

Discussing the situation with the nurse manager

A nurse is assisting a new nursing graduate with organizational skills in delivering client care. The nurse determines that the new nursing graduate needs assistance with time management if he:

Documents task completion and client information at the end of the day

Which of the following actions exemplifies the use of evidence-based practice in the delivery of client care?

Donning sterile gloves to change an abdominal wound dressing

A client receives cefazolin sodium (Ancef) by way of the intravenous route. During the infusion, the client begins exhibiting signs of an allergic reaction. The client states that his skin is itchy, and the nurse notes that the skin is warm and flushed, with a red rash on the arms, chest, and back. The nurse immediately discontinues the medication, further assesses the client, contacts the physician, and begins to document the reaction in an incident report. The nurse most accurately documents which of the following?

During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The physician was notified.

The registered nurse has accepted a new position as case manager in a hospital. Which of the following responsibilities are part of the nurse's new role? Select all that apply.

Evaluating and updating the plan of care as needed Assessing the client's needs for home supplies and equipment Coordinating consultations and referrals to facilitate discharge Establishing a safe and cost-effective plan of care with the client

A physician asks the nurse who is caring for a client with a new colostomy to ask the hospital's stoma nurse to visit the client and assist the client with care of the colostomy. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client because of his:

Expert power

A nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. The nurse should:

Explain to the client why the wedding band must be removed

A married couple is attending a hospital program about in vitro fertilization. During the program, a crew from a local television station arrives to film the proceedings because the station is publicizing a series on hospital services. The nurse conducting the program should:

Explain to the television crew that videotaping is not allowed

A client with diabetes mellitus who takes a daily dose of NPH insulin has a hard time drawing the insulin into a syringe because he has difficulty seeing the markings on the syringe. To which of the following services does the nurse suggest a referral?

Home care

The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which of the following actions should the auditing nurse plan to perform in this type of audit?

Obtaining the assigned medical record from the hospital's medical record room to review documentation made during a client's hospital stay

A client who had a stroke has left-side weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral?

Occupational therapy

A new nurse employed at a community hospital is reading the organization's mission statement. The new nurse understands that this statement:

Outlines what the organization plans to accomplish

A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?

Oxygenating the client with 100% oxygen

An emergency department nurse is performing an assessment of a client who has sustained circumferential burns of both legs. What should the nurse assess first?

Peripheral pulses

Which of the following situations is an example of the use of evidence-based practice in the delivery of client care?

Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin

A nurse manager notes that an employee is constantly calling in sick. Which action should the nurse manager take initially to handle this problem?

Reminding the employee of the employment standards of the agency

A nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. The most appropriate action for the nurse is to:

Report the incident to the nursing supervisor

A client who has undergone a total hip replacement is told that she will need to go to an extended care rehabilitation facility for therapy before going home. Which member of the healthcare team does the nurse ask to plan the discharge and transition from the hospital to the rehabilitation facility?

Social worker

A nurse is assisting a client with a closed chest tube drainage system in bathing. As the nurse is turning the client onto his side, the chest tube is disconnected. What should the nurse do first?

Submerge the end of the chest tube in a bottle of sterile water

The nursing instructor asks a student to name an example of false imprisonment. Which of the following situations reflects a violation of this client right?

Telling the client that he or she may not leave the hospital

A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, "I don't want a bath. I've been up all night, and I'm clean enough." The student reports the client's refusal to the nurse in charge. Which action by the nurse in charge is appropriate?

Telling the nursing student to allow the client to rest

A physician informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The physician tells the nurse to perform a "slow code" and let the client "rest in peace" if she stops breathing. How should the nurse respond?

Telling the physician that "slow codes" are not acceptable

A nurse calls a physician to question a prescription written for a higher-than-normal dosage of morphine sulfate. The physician changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency's guidelines in the client's record. Which other statement does the nurse document in the nursing notes?

The physician was called to clarify the prescription for morphine sulfate.

A nurse is supervising a new nursing graduate in various procedures. Which of the following actions by the new nursing graduate constitutes a negligent act?

Using clean gloves to change a gastrostomy tube dressing