VN 500 1901 AP DELEGATION 0219
A male client tells the nurse that he does not want the female assistive personnel involved in his care. Which of the following statements should the nurse give?
" I'll notify the charge nurse of your request to have only male staff members assigned to care for you"
A charge nurse in a long - term care facility is reviewing client outcomes when delegating tasks to assistive personnel (AP) with newly licensed nurse. Which of the following statements should the charge nurse include in the teaching?
" The final step in delegation is evaluation of the outcomes."
A nurse in a long-term care facility is reinforcing teaching about safe delegation practices with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?
" delegated tasks require follow-up to ensure compliance"
A charge nurse overhears a newly licensed nurse providing instructions to a female client on the proper steps to collect a midstream urine specimen. Which of the following statements made by the newly licensed requires the charge nurse to intervene?
" use the provided towelette to cleanse the are by moving in a back and forth motion"
A nurse is caring or a client who is scheduled for a surgery. The client states, " i have changed my mind and i don't want the surgery." Which of the following responses should the nurse give?
" you an change your mind about the surgery at any times."
A nurse is assisting with the care of a group of clients on a gynecology unit. Which of the following clients should the nurse attend to first?
A client who was admitted 1 hr ago for an ectopic pregnancy
A nurse witnesses an adult who is experiencing a cardiac arrest while at the grocery store. The nurse performs CPR. Which of the following criteria is necessary for the Good Samaritan law to provide civil immunity for the nurse?
The nurse has basic life support certification
A nurse is preparing to perform a urinary catheterization to obtain a urine specimen for a client. The client tells the nurse that she is concerned about her privacy during the procedure. Which of the following actions should the nurse take to alleviate the client's concern?
close the door and cover the client during the procedure
A nurse is reinforcing teaching with a newly hired assistive personnel who is assisting with the care of a client who has an indwelling urinary catheter. Which of the following
close the tubing clamp when transferring the client from the bed to a chair
A licensed practical nurse is planning care for a group of clients and is delegating tasks to an assistive personnel. Which of the following tasks should the LPN perform?
insert a NG tube for a client who has abdominal distention
A staff nurse suspects that a newly licensed nurse is chemically impaired. Which of the following actions should the staff nurse take?
notify the charge nurse of the situation
A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take?
wrap sheepskin around the wrist before applying the restraint
A nurse tells another nurse that she thinks that he did not provide adequate care for a client who underwent a hip arthroplasty earlier that day. Which of the following responses by the accused nurse demonstrates assertiveness?
" i feel as though i met the standard of care. Would you tell me more about your concerns?"
A nurse is working with an assistive personnel who refuses a client assignment. When resolving this conflict, which of the following comments is appropriate for the nurse to make?
" i need to talk to you about the unit policies regarding client assignments."
A nurse is working with two assistive personnel. The nurse notes that one of the APs has been taking long breaks and making personal phone calls. Which of the following statements should the nurse make to resolve this conflict?
" i need to talk to you about unit expectations regarding timely completion of tasks"
A nurse is reinforcing teaching with a newly licensed nurse about limit-setting for a client who exhibits manipulative behaviors. Which of the following responses by the newly licensed nurse indicates further teaching is needed?
" i will bargain with the client about consequences"
A nurse has assigned client care activities to an assistive personnel. Which of the following statements by the AP indicates a need for assistance in establishing priorities?
" i will start with room 1, then work my way to room 10"
A nurse is caring for a client. One of the client's family members requests to view the client's medical record. Which of the following responses should the nurse make?
" the client must provide written permission to share the record"
A nurse has received report from an RN on a group of newly assigned clients. Which of the following statements by the RN during report indicates that the nurse should assume total care for the client, rather than assigning tasks to the assistive personnel?
" the client's blood pressure and pulse have been
A nurse is obtaining informed consent from a client who is scheduled for a total hip arthroplasty. Which of the following statements should the nurse included?
" your provider will discuss other treatment options"
A nurse is caring for several clients on a medical-surgical unit. Which of the following client care situations requires the nurse to complete an incident report?
A client tells the nurse that his dentures are missing
A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse attend to first?
A client who has a blood glucose level of 68 mg/dL and reports mild sweating
A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan ti see first?
A client who requests pain medication
A nurse is reinforcing teaching with a group of newly licensed nurses about completing an incident report. For which of the following situations should the nurse complete an incident report?
A client's family member becomes short and reports having chest pain.
A nurse is caring for a client who asks if home oxygen will be provided to her after discharge. Which of the following actions should the nurse take?
Consult the case manager
A nurse is assisting with the care of a group of pediatric clients. Which of the following actions should the nurse take first?
Deliver a breakfast tray to a child who has been administered regular insulin.
A nurse mistakenly administers a dose of metformin within 1 hr of the previous dose. Which of the following findings should alert the nurse that the client is experiencing and adverse effect from the medication error?
Diaphoresis and tachycardia
A nurse asks an assistive personnel (AP) to take a specimen to the laboratory and the AP refuses. Which of the following actions should he nurse take?
Discuss the incident with the AP.
A nurse is caring for a client who has pneumonia and is coughing up secretions. Which of the following actions should the nurse take first?
Encourage the client to cough and deep breathe
A medical surgical unit has implemented a policy change. The nurse manager has noticed that one of the nurses, who has a history of being resistant to change, is not delivering care according to the new policy. Which of the following actions should the nurse manager take?
Encourage the nurse to verbalize the reasons for resistance to the change.
A nurse is reinforcing teaching to a client about advance directives. Which of the following topics should the nurse include?
Enteral feeding tubes,, cardiopulmonary resuscitation, durable power of attorney for health care
A nurse is assisting with revising a facility's emergency response plan for tornado disasters in the community. The nurse should plan to collaborate with which of the following agencies?
Federal Emergency Management Agency
A nurse on a pediatric unit is working with an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first?
Feed a school-age client who has burns on both upper extremities.
A charge nurse is discussing emergency response with a newly licensed nurse. The charge nurse should identify which of the following as a triage officer during the time of a disaster?
Nurses and other emergency medical personnel
A nurse is caring for a group of clients on a medical surgical unit. Which of the following tasks is unsafe to assign to an assistive personnel (AP)?
Observe a confused surgical client who has multiple tubes
A nurse is preparing to obtain consent from a client who has a tibia fracture. The client received IV morphine sulfate prior to arrival on the unit and is scheduled for surgery. Which of the following actions should the nurse take?
Obtain consent from a relative of the client.
A nurse enters a client's room to answer the call light and sees the client and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?
Obtain the client's vital signs
A nurse is preparing to perform a urinary catheterization for an older adult client who speaks a different language than the nurse. Which of the following actions should the nurse take to explain the procedure to the client?
Provide an interpreter to explain the procedure.
A nurse is caring for a client who has a left-sided stroke and is now having difficulty swallowing. For which of the following health care providers should the nurse recommend a referral to assist the client with swallowing?
Speech therapist
A nurse on a medical unit is planning the shift assignments. The nurse may delegate collection of which of the following specimens to an assistive personnel?
Sputum specimen, stool specimen, unrinalysis
A nurse is receiving change-of-shift report of several clients. Which of the following activities should the nurse plan to attend to first?
Suction the tracheostomy of a client who has copious secretions.
A nurse is performing care for several clients with the help of an assistive personnel. Which task should the nurse ask the AP to perform first?
Take an ABG specimen to the laboratory
A nurse is caring for a group of clients on a medical-surgical unit. The nurse delegates various tasks the clients require to another licensed practical nurse (LPN) and an assistive personnel. The nurse should identify that the responsibility for making sure the client received the care the plan of care specifies belongs to which of the following team members?
The nurse who delegated the tasks
A nurse is caring for an infant who has respiratory syncytial virus. Which of the following actions should the nurse take?
Wear a gown when changing the infants diaper
A nurse is caring for a group of clients with the help of an assistive personnel. Which of the following determinations must the nurse make before delegating a client care task to the AP?
Whether the task is within the AP's job description
A nurse is assisting with planning an in-service for staff nurses about disaster management ad triage. Which of the following color tags should the nurse include as identifying a client who requires treatment within 30 min to 2 hr?
Yellow
A nurse working in a long-term care facility is assigned care of four clients following the 0700 morning change-of-shift report. Which of the following clients should the nurse attend to first?
a client who has diabetes, and had a 0600 blood glucose level of 60 mg/dL
A nurse is assisting with implementing new actions designed to reduce medication errors on her unit. Which of the following should the nurse use to measure the effectiveness of these actions?
a comparison of the number of medication errors before and after the actions were implemented
A nurse is planning to assign care activities to the assistive personnel. Which of the following activities are appropriate for assignment to the AP?
accompanying a client who has depression to occupational therapy, checking the position of a client who is soft wrist restraints, sitting with a client who has alcohol use disorder whose last drink was 4 days ago.
A nurse is assisting a client who is 2 days postoperative following a total hip arthroplasty to a chair. When the nurse offers to help the client ambulate, the client refuses to get out of bed. Which of the following actions should the nurse take?
acknowledge the client's wishes
A charge nurse is observing a newly licensed nurse perform client care. Which of the following situations requires intervention by the charge nurse?
administering an antibiotic medication to a client 1 hr prior to the prescribed time
A nurse on a pediatric unit has received change-of-shift report. Which of the following clients should the nurse plan to see first?
an infant who has pertussis and is receiving oxygen via nasal cannula
A nurse observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse take?
approach the man and ask why he is making copies
A nurse is caring for four clients on a surgical unit. Which of the following tasks should the nurse delegate to the assistive personnel?
assist a client to a chair who is 2 days postoperative following a cervical laminectomy
A nurse in a long-term care facility is delegating tasks to an assistive personnel. Which of the following tasks should the nurse assign the AP?
attending to a client who has fallen out of bed
A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel?
bathe a client who has an amputation 2 days ago, assist a client to ambulate using a gait belt, feeding a client who had a stroke 3 months ago
A nurse is planning care for a group of clients on a medical-surgical unit. Which of the following actions should the nurse take first?
collecting data from a client who reports unilateral calf pain when ambulating
A nurse is planning an in-service that encourages active member participation and feedback about decreasing nosocomial infections on the unit. Which of the following leadership styles does the nurse plan to use?
democratic
A charge nurse in a long- term care facility has assigned care for a group of clients to an assistive personnel. The charge nurse observes the AP chatting sociably with peers, learns that the AP left the unit
discuss the assigned tasks with the AP
A nurse applies wrist restraints to a client who is confused and attempting to pull out a chest tube. Which of the following actions should the nurse take?
document what less-restrictive interventions she tried
A licensed practical nurse is working with an RN to deliver care to a group of clients. Which of the following tasks should the LPN plan to complete?
performing a dressing change for a client who is 2 days postoperative following a total hip arthroplasty
A nurse is assigning care to an assistive personnel. Which of the following tasks should the nurse delegate to the AP?
providing postmortem care on a client who has died
A nurse enters the hospital cafeteria for lunch and overhears two assistive personnel discussing a client who is currently hospitalized. Which of the following actions should the nurse take?
quietly tell the APs that the conversation is inappropriate
A nurse on a medical-surgical unit is providing care for a client who is a hospital employee. Several nurses have called seeking information about the client. Which of the following actions should the nurse in response to inquiries from the nurse?
refer questions to the nursing supervisor
A nurse is planning care for a group of clients and is reviewing tasks to be delegated the assistive personnel. Which of the following tasks should the nurse complete?
removing and cleaning the cannula of a client who has a new tracheostomy
A float nurse is given a client assignment that requires the use of unfamiliar skills and techniques. Which of the following actions should the nurse take?
request the charge nurse to modify the assignment
A charge nurse in a long-term care facility checks with other nursing personnel on the unit throughout the day to determine if they are completing tasks. Which of the rights of delegation is the nurse demonstrating?
right supervision
A nurse requests requests that an assistive personnel change all the linens and give bed baths to four clients on the unit. The previous day, the AP was not able to complete these same tasks. Which of the following actions should the nurse take in addressing this situation?
set a time frame for the AP to complete the tasks the assignment includes
A nurse observes another nurse performing a procedure in the incorrect sequence. The procedure does not harm the client. Which of the following actions should the nurse take first ?
speak with the other nurse privately
A nurse is contributing to the plan of care for a client who has dysarthria. Which of the following referrals should the nurse recommend?
speech - language pathologist
A nurse enters the room of a client who is confused and finds the client sitting on the floor. After determining hat the client is free from injury, and completing an incident report which of the following actions should the nurse take?
submit the incident report to the risk manager
