The nurse is preparing assignments for the day shift. It is most important that the client with which diagnosis and description is assigned to a
... [Show More] registered nurse?
Menorrhagia: 24 hours post vaginal hysterectomy.
Myocardial Infarction: 4-days post infarction, transferred from ICU yesterday.
Depression: Admitted during the night, following a suicide attempt with an overdose of Tylenol.
Pneumonia: A 4-year-old who is receiving IV antibiotics. - Depression: Admitted during the night, following a suicide attempt with an overdose of Tylenol.
Rationale
The client with depression who was admitted during the night, following a suicide attempt with an overdose of Tylenol requires communication skills and assessment skills beyond the educational level of a practical nurse or UAP. Establishing a therapeutic, one-to-one relationship with a depressed client is beyond the scope of practice for a practical nurse. Additionally, tylenol is extremely hepatotoxic and careful assessment is essential.
The charge nurse working the 3 to 11 shift of a 24-bed medical unit in a large acute care hospital is making assignments. Currently, there are 20 clients on the unit and 4 admissions are scheduled to arrive during the shift. Besides the charge nurse, the staff consists of two experienced practical nurses (PN) and one unlicensed assistive personnel (UAP) who has worked on the unit for 10 years. Taking into consideration the acuity of each client, which distribution of clients is the best assignment for the nurse to make?
10 clients and 2 admissions to each of the PNs. Have the UAP take all vital signs and collect all I&Os.
10 clients to each of the PNs. Have the UAP take vital signs. The charge nurse takes the 4 new admissions.
8 clients to each of the PNs, 4 clients to the charge nurse, and the 4 admissions to the UAP.
8 clients to each of the PNs, 4 admissions to the charge nurse, and 4 low-acuity clients to the UAP. - 10 clients to each of the PNs. Have the UAP take vital signs. The charge nurse takes the 4 new admissions.
Rationale
Considering acuity level, it is best for the nurse to assign 10 clients to each of the PNs, have the UAP take vial signs and collect I&Os and the charge nurse care for the new admissions since they will all require assessment by the RN. The charge nurse should take the new admissions.
The nurse is designing a program to control nosocomial infections on a geriatric unit of an acute care hospital. What strategy should be included in this plan?
Do not allow those with influenza to be admitted to the unit.
Require that all clients receive a pneumonia vaccine prior to admission.
Ensure that sterile technique is followed when changing surgical dressings.
Encourage clients to drink water to prevent urinary tract infections. - Ensure that sterile technique is followed when changing surgical dressings.
Rationale
A nosocomial infection is one that was not present or incubating at the time of admission, and using appropriate sterile technique and medical asepsis helps to prevent this type of infection from occurring. The other options are infection preventive techniques, but are not specific to the prevention of nosocomial infections.
A nurse who works in an acute minor illness clinic returns from lunch and finds several clients who need attention. Which client should the nurse attend to first?
A 10-year-old with asthma who is responding well to nebulizer treatments.
A three-week-old infant who is nursing and was brought in because he had a fever.
A 4-year-old receiving intravenous fluid for dehydration whose IV fluid bag is empty.
A 6-year-old with Down syndrome who has been coughing productively. - A 4-year-old receiving intravenous fluid for dehydration whose IV fluid bag is empty.
Rationale
The nurse should attend to the child who is dehydrated and receiving IV fluids first. Not knowing how long the fluid bag has been empty, the nurse should hang a new bag, see if it flows, and if not, assess for infiltration.
The nurse is caring for 4 clients on an orthopedic floor: 2 clients with total hip replacements, one client with total knee replacement, and one client with a fractured femur who is in skeletal traction. Which nursing task should the nurse delegate to the unlicensed assistive personnel (UAP)?
Adjust the setting on the continuous passive motion machine (CPM).
Clean the skeletal traction insertion sites while performing a.m. care.
Assist the client to ambulate for the first time after surgery.
Change the linens for the client with skeletal traction. - Change the linens for the client with skeletal traction.
Rationale
The client in skeletal traction cannot get out of the bed, so the UAP should change the linens with the client in the bed. The other options are beyond the scope of the UAP and should not be delegated. [Show Less]
