280 midterm-2.docx

1. A new graduate nurse is making staff assignments. He assumes responsibility for all clients needing IV medications and high level assessment skills and gives responsibility for the remaining clients to other personnel ...

1. A new graduate nurse is making staff assignments. He assumes responsibility for all clients needing IV medications and high level assessment skills and gives responsibility for the remaining clients to other personnel. This is an example of which error in delegation? 2. A nurse is planning care for four clients and is assigning tasks to an LPN and an AP. Which of the following should the nurse assign to the LPN? 3. A nurse is orienting a group of new graduate nurses and explains the purpose of delegation. Which of the following is an appropriate statement by the nurse? 4. The charge nurse is delegating tasks to nursing personnel on a 10-bed med surg. unit. Which of the following is an example of over delegation? 5. A nurse is working with the AP and reviewing the list of tasks that have been delegated to the AP by the charge nurse. Which of the following tasks require clarification? 6. When delegating, what would you consider as most important in regards to providing to the person you’re delegating to? 7. A nurse manager is reviewing safe delegation practices with nurses on the unit. Which of the following is an appropriate statement by the nurse manager? 8. A nurse is planning to delegate a task to an AP. Which of the following does the nurse consider? 9. An RN is delegating care activities to an LPN. Which of the following is the priority criteria the RN considers when delegating? 10. How do you confront a client who is not willing to comply? 11. A nurse manager notices that the nurse on the unit is not delivering care in accordance with a recent policy change. The effective approach for the nurse manager to take is to? 12. What can you assign to the UAP? Take patient to x-ray Check the restraints on a patient and report any changes to the RN. 13. An AP reports to the nurse that a client who has returned to the unit following an abdominal hysterectomy has a dressing which is saturated with blood. Which of the following tasks should be delegated to the AP? Obtaining the vital signs 14. A nurse is planning to assign care activities to the AP. Which of the following activities are appropriate for assignment to the AP? Accompanying a client with depression to OT Checking the position of the client in soft wrist restraints Sitting with a client with alcohol abuse whose last drink was 2 days ago 15. A nurse is working with a group of clients assisted by an AP. The nurse should make which of the following determinations before delegating a task to the AP? The task is within the scope of practice for the AP 16. How do you protect patient confidentiality and privacy? Durable power of attorney is the only family member that can have medical information disclosed to them 17. What type of patient would you assign to the float nurse in your unit? The more stable patient 18. An RN from L&D is being floated to a med. surg. unit. Which of the following clients should the charge nurse on the med. surg. unit plan to assign to the RN? A client who is one day post op following a total abdominal hysterectomy 19. A nursing supervisor assigns a float nurse in an adult med. surg. unit to work in a peds unit. This is the nurse’s first time in a peds setting. Which of the following is an appropriate assignment for the nurse? Care for post op school-aged clients 20. What is the goal of delegation? Patient outcome, time management 21. A nurse is orienting a group of new graduate nurses and explains the purpose of delegation. Which of the following is an appropriate statement by the nurse? Delegation permits a designated individual to meet a goal on your behalf 22. A nurse is caring for several clients in a walk-in clinic. Which client should the nurse have the provider see first? A diaphoretic, obese middle-aged man with epigastric pain 23. A nurse is planning to use an SBAR communication tool when calling a provider. Which of the following statements by the nurse is appropriate for the B step in this tool? Client was found unconscious on the floor in her home 24. A nurse makes a medication error. She immediately assesses the client and determines that the client has had no untoward effects of the error. The nurse decides not to report the error because no harm came to the client. Which of the following ethical principles did the nurse violate? Veracity 25. A nurse has assigned client care activities to an AP. Which statement by the AP indicates a need for assistance in establishing priority? I have my assignments and will start with room 1 and work my way to 10 26. A nurse overhears two APs discussing a hospitalized client while in the cafeteria. Which of the following is the most appropriate nursing actions? Quietly tell the APs that this is not appropriate 27. How would you ensure your UAP is following infection control protocol? Teach handwashing 28. A nurse is learning to start a client IV. Which of the following hand hygiene practices by the nurse requires further teaching? Uses an alcohol-based hand scrub when hands are visibly soiled 29. A nurse is caring for a client who is post op. The nurse signs as a witness on the client’s procedural consent forms. By signing as a witness, the nurse is verifying that It was the client who signed the consent form 30. A nurse is obtaining informed consent from a client prior to surgery. Which of the following is necessary for informed consent to be valid? Disclosure of the treatment is provided Client understands the surgical procedure Voluntary consent is given 31. A nurse is speaking to the nurse manager about a schedule request and the nurse manager puts an arm around the nurse and says “I bet you are a great lover.” Which of the following is the appropriate response by the nurse? Speaking to me like that makes me uncomfortable 32. A staff nurse has applied for a transfer to another unit. When the nurse approaches the nurse manager, the nurse manager asks the nurse to go out on a date and insinuates that if there was a sexual relationship between them, the nurse’s transfer request would get increased consideration. The first action that the staff nurse should take in this situation is to Tell the nurse manager in clear terms that this conduct is causing feelings of discomfort and that the behavior should stop immediately 33. A nurse is asked to assist in the CQI program to reduce the number of mediation administration errors. The nurse should recognize that which of the following strategies is appropriate initially? Review the events leading up to each medication administration error 34. An AP comes to work with a new set of highly polished acrylic nails. The nurse takes the AP aside and explains that the acrylic nails are not permitted on the health care unit. Which of the following statements should the nurse tell the AP? There is a higher risk of infection with acrylic nails 35. What kind of patient would be placed by the nurse’s station? A patient with changing conditions, altered level of consciousness, dementia, fall risk 36. A nurse is caring for an older client who was alert and oriented. After four days of hospitalization, the client seems to be increasingly restless and intermittently confused. What is the most appropriate nursing intervention to address the safety needs of the client? Move the client to a room closer to the nurse’s station 37. A nurse is caring for a client who is on isolation for active pulmonary TB. Which of the following precautions should the nurse include when creating a sign to post outside of the client’s room? Mask (N95) Keep door closed Sharp’s container Hand washing 38. Describe the proper use of a cane Cane should always go first. Cane is on the STRONG side. If there is a person assisting, the person is on the weak side. If there is no cane, the person is on the strong side. (Cane on strong side goes first, then weak side, followed by strong side) 39. A nurse has several tasks to delegate to an AP. Which of the following tasks should the nurse ask the AP to perform first? Take the ABG specimen to the lab 40. A nurse is caring for a group of clients as a part of a team that includes an experienced LPN. When organizing the assignments, the nurse lists several tasks that must be completed. Which of the following tasks should the nurse recognize may be safely delegated to LPN? Obtaining frequent vitals on a post op client Administering a tap water enema to a post op client Changing a dry, sterile dressing on a client’s incision Catheterizing a client who has not voided in 8 hours 41. A charge nurse is making assignments for nursing personnel who will be caring for clients during the oncoming shift. Which of the following does the charge nurse consider? Information needed by nurses to perform the assigned tasks 42. What task would be assigned to the RN as opposed to the LPN? Transferring a patient from PACU 43. A nurse manager is assigning care responsibilities for the upcoming shift. A client is awaiting transfer back to the unit from the PACU following hip arthroplasty. To which staff member should the nurse assign the client? RN 44. A charge nurse directs an LPN to change a client’s dressing. Several hours later, the client reports that the dressing has not been changed. Which of the following actions should the charge nurse take? Verify that the LPN knows how to do the dressing change 45. An RN is planning to delegate tasks to an LPN. Which of the following is important for the nurse to understand when delegating tasks to the LPN? The state nurse practice act 46. A nurse is assisting an older client to the bathroom when the client falls and breaks a hip. The client says he will sue the nurse for negligence because of the fall. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse is liable for the client’s injury will be which of the following? Another staff nurse’s description of how a reasonably prudent nurse should have performed under the same circumstances 47. A nurse enters a client’s room and finds the client pulseless. The family has requested a DNR order from the provider, but he has not written the order yet. Which of the following actions should the nurse take? Call the emergency response team 48. A nurse is preparing an Inservice for a group of newly license nurses about the use of the new infusion pump. What teaching strategy ensures that the staff can use the device safely? Demonstrate using the device and observe the staff returning the demonstration 49. New IV pumps are being delivered to a med. surg. floor. Which of the following training options should the charge nurse use to best evaluate staff competency with the new equipment? Allow time during the workday when each nurse can demonstrate proficiency 50. A charge nurse is planning care for four clients on a medical unit. Which of the following tasks should the nurse delegate to an AP? Ambulate a client who has a cane Transfer a client to a stretcher Record urinary output 51. A nurse is delegating client care assignments for the shift. Which of the following tasks would be appropriate for the nurse to delegate to the AP? Collecting I&O 52. A nurse is caring for several clients. For which of the following situations should the nurse complete a variance report? Client discovers his dentures are missing 53. When checking on a confused client, a nurse finds that the client has fallen out of bed after climbing over the side rails. After determining that the client is uninjured, the nurse assists the client back to bed and contacts the provider to report the incident. The nurse then completes a variance report detailing the incident. Which of the following should be the next nursing actions the nurse completes? Submit the variance report to the nurse manager 54. A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the AP? Monitoring vital signs of a client who had an appendectomy 12 hours ago 55. An AP reports to the nurse that a client who has returned to the unit following an abdominal hysterectomy has a dressing which is saturated with blood. Which of the following tasks should be delegated to the AP? Obtaining the vital signs 56. A nurse on a med. surg. unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer? Observing a post op client who is confused 57. A female teen volunteer is assigned on the peds unit for the day and reports to the charge nurse for the assignment. Which of the following assignments is unsafe for the volunteer? Helping a 7-year-old with celiac disease with the next day’s menu 58. A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan on seeing first? A client asking about his PCA pump containing morphine 59. A nurse is assessing four clients on a med. surg. unit. Which of the following should the nurse attend to first? A client who has a cast on the left leg and reports numbness and paresthesia 60. A nurse is assigned four post op clients. Which of the following clients should the nurse address first? A client whose BP @ 0800 was 138/86 and @ 1200 was 106/60 61. A nurse has received morning report on the following four clients. Which client should the nurse see first? A client who has a blood glucose of 68 and reports mild sweating