What can be delegated to Assistive personnel (AP)?
ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow
precautions) -
... [Show More] positioning - bed making - specimen collection - I&O - VS (stable
clients
A nurse on a med surge unit has recieved change of shift report and will care for 4
clients. Which of the following clients needs will the nurse assign to an AP?
C. Reapplying a condom catheter for a client who has urinary incontinence
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to
an AP. Which of the following info should the nurse share with the AP?
Select all:
B. The client ambulates with his slippers on over his antiembolic stockings
C. The client uses a front wheeled walker when ambulating
D. The client had pain meds 30 minutes ago
An RN is making assignments for client care to an LPN at the beginning of the shift.
Which of the following assignments should the LPN question?
D. Replacing the cartridge and tubing on a PCA pump
A nurse is preparing an inservice program about delegation. Which of the following
elements should she identify when presenting the 5 rights of delegation. Select all:
B. Right supervision/evaluation
C. Right direction/communication
E. Right circumstances
A nurse manager of a med surge unit is assigning care responsibilities for the oncoming
shift. A client is waiting transfer back to the unit from the PACU following thoracic
surgery. To which staff member should the nurse assign the client?
B. RN
What is the study of conduct and character? Ethics
What are the values and beliefs that guide behavior and decision making?-Morals
What is the right to make ones own personal decisions, even tho those decisions might
not be in the persons best interest-Autonomy
What are positive actions to help others-Beneficience
What is an agreement to keep promises-Fidelity
What is fairness in care delivery and use of resources-Justice
What is avoidance of harm or injury-Non-maleficence
A nurse is caring for a client who decides not to have surgery despite significant
blockages in his coronary arteries. The nurse understands that this clients choice is an
example of what principles?
A. Fidelity
A nurse offers pain meds to a client who is postop prior to ambulation. The nurse
understands that this aspect of care delivery is an example of which of the following
ethical principles?
D. Beneficience-D
A nurse is instructing a group of nursing students about the responsibilities involved with
organ donation and procurement. When the nurse explains that all clients waiting for a
kidney transplant have to meet the same qualifications, the students should understand
that this aspect of care delivery is an example of which ethical principle
C. Justice
A nurse questions a med prescription as too extreme and light of the clients advanced
age and unstable status. The nurse understands that this action is an example of which
ethical principle
D. Nonmalificence
Which of the following situations can be identified as an ethical dilemma?
C. A family has conflicting feelings about the initiation of enteral tube feedings of
their father who is terminally ill
Most managers can be categorized as-authoritative, democratic, and laissez faire
Authoritative
makes decisions of the group
motivates by coercion
communication occurs down the chain of command
Work output by the staff is usually high-good for crisis situations and bureaucratic
settingsDemocratic
includes the group when decisions are made
Motivates by supporting star achievements
Communication occurs up and down the chain of command
Work output by staff is usually of good quality-good when cooperation and
collaboration is necessaryLaissez faire
makes very few decisions and does little planning
motivation is largely the responsibility of individuals staff members
Communication occurs up and down the chain of command and between group
members
Work output is low unless an informal leader evolves from the group
*the use of any of these styles may be appropriate depending on the situationThe nurse should consider the hierarchy of human needs when prioritizing interventions,
which are?—
-Physiological needs first (oxygen, shelter, food)
- Safety & security needs (physical safety)
- Love and belonging
- Self esteem
- Self actualization
The ABC framework identifies, in order, the three basic needs for sustaining life-
Airway
Breathing
Circulation
Nurses must follow what code of standards in delegating and assigning tasks-
ANA codes of standards
What values would a nurse possess to be a client advocate?- CARE
- caring
- autonomy
- respect
- empowerment
What do the nurse need to keep in mind about the client when being their advocate?-
Client's religion & culture
When should planning discharge process begin?
a. at time of admission
What is an interdisciplinary team?-
A group of health care professionals from different disciplines
Fill in the blank:
1. collaboration is used by interdisciplinary team to make health care decisions
about clients with multiple problems.
2. collaboration, which may take place at team meetings, allows the achievement
of results that the participants would be incapable of accomplishing if working
alone
What is the nurse's contribution to an interdisciplinary team?-
- knowledge of nursing care & its management
- a holistic understanding of the client, her/his healthcare needs &
healthcare systems.
A four-month-old infant is admitted to the pediatric intensive care unit with a temperature
of 105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which
assessment finding would indicate an increase in intracranial pressure?
2. High-pitched cry.
A client is receiving total parenteral nutrition (TPN). To determine the client's tolerance of
this treatment, the nurse should assess for which of the following?
4. Urine output of at least 30 cc per hour.-4
The client is exhibiting symptoms of myxedema. The nursing assessment should reveal
2. decreased temperature.
A nonstress test is scheduled for a client at 34-weeks gestation who developed
hypertension, periorbital edema, and proteinuria. Which of the following nursing actions
should be included in the care plan in order to BEST prepare the client for the diagnostic
test?
3. Instruct client to push a button when she feels fetal movement.
Which of the following nursing interventions is MOST important for a 45-year-old woman
with rheumatoid arthritis?
4. Assist her with heat application and ROM exercises.-4
The nurse is caring for a young adult admitted to the hospital with a severe head injury.
The nurse should position the patient
1. with his neck in a midline position and the head of the bed elevated 30°.
The nurse is teaching a 40-year-old man diagnosed with a lower motor neuron disorder
to perform intermittent self-catheterization at home. The nurse should instruct the client
to
2. perform the Valsalva maneuver(holding breath and bearing down) before doing
the catheterization.
A client is being discharged with sublingual nitroglycerin (Nitrostat). The client should be
cautioned by the nurse to
4. avoid abrupt changes in posture.-4
A 38-year-old woman is returned to her room after a subtotal thyroidectomy for treatment
of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside,
is nonessential?
1. Potassium chloride for IV administration.
A nurse recognizes that an initial positive outcome of treatment for a victim of sexual
abuse by one parent would be that the client
3. verbalizes that s/he is not responsible for the sexual abuse.
An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg PO bid.
Which of the following instructions should be given to this client by the nurse?
2. "Wear sunscreen and a hat when outdoors. [Show Less]