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10 Cards in this Set
- Front
- Back
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A nurse is working with the interdisciplinary team to promote and maintain independence, and maintain health for a child with a spinal cord injury (SCI). Which of the following interventions are appropriate? Select all that apply. |
Select one or more: a. Evaluating bowel training
b. Discussing sexuality issues
c. Encouraging annual flu vaccinations
d. Evaluating food choicese. Promoting an exercise program
Answer
a. Evaluating bowel training
CORRECT. Effective bowel training that allows the client to be continent of stool will foster independence in the SCI client.
c. Encouraging annual flu vaccinations
CORRECT. An SCI client should take measures to prevent illnesses such as receiving the flu or pneumonia vaccination.
d. Evaluating food choices
The nurse should promote a high fiber diet with increased fluid intake to assist with bowel and bladder training. At discharge an appropriate intervention would be to evaluate food choices made by the client.
e. Promoting an exercise program
The nurse should make certain that structured exercise is provided through physical or occupational therapy to promote strength and endurance.
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According to the American Hospital Association’s Patient Care Partnership, the nurse understands that client rights in the health care setting include which of the following? Select all that apply. |
Select one or more: a. Help with billing and filing insurance claims
b. Assistance with childcare arrangements
c. Preparation for discharge
d. Client involvement in the plan of care
e. Arrangements for home follow-up visits
Answer
c. Preparation for discharge
Correct: The Patient Care Partnership identifies high quality of care, protection of client privacy, involvement in care, help when leaving the hospital, and help with billing claims as client rights during a hospital stay. Therefore, the correct answers of B, C, and E are directly applicable.
d. Client involvement in the plan of care
Correct: The Patient Care Partnership identifies high quality of care, protection of client privacy, involvement in care, help when leaving the hospital, and help with billing claims as client rights during a hospital stay. Therefore, the correct answers of B, C, and E are directly applicable.
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A charge nurse is managing a conflict between co-workers. Which of the following are effective management functions for conflict resolution? Select all that apply. |
Select one or more: a. Avoid facilitating conflict resolution involving subordinates.
b. Create a work environment that minimizes the conditions for conflict.
c. Suppress the need for closure and follow-up to negotiation.
d. Obtain needed unit resources through effective negotiation strategies.
e. Pursue alternative dispute resolutions when conflict cannot be resolved.
Answer
b. Create a work environment that minimizes the conditions for conflict.
CORRECT. Creating a work environment that minimizes the conditions for conflict is a critical leadership skill for conflict resolution.
d. Obtain needed unit resources through effective negotiation strategies. CORRECT. Obtaining needed unit resources through effective negotiation strategies is a critical leadership skill for conflict resolution.
THESE ARE INCORRECT RATIONALE
c. Suppress the need for closure and follow-up to negotiation.
INCORRECT. Suppressing the need for closure and follow-up to negotiation is not an effective management function for conflict resolution. Addressing the need for closure and follow-up to negotiation is a critical leadership skill for conflict resolution.
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Which of the following client care assignments is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
Select all that apply. |
Select one or more: a. Assist a client with a new transurethral prostectomy with perineal care.
b. Apply a dressing to a superficial laceration on the client’s arm.
c. Provide initial food by mouth for a client who has experienced a brain attack.
d. Obtain vital signs every 4 hours for a client with ulcerative colitis.
e. Transport a client who is utilizing oxygen and has a peripheral IV catheter.
Answer
a. Assist a client with a new transurethral prostectomy with perineal care.
CORRECT. Assisting a client who recently experienced a transurethral prostectomy is a task that can be delegated to the UAP.
d. Obtain vital signs every 4 hours for a client with ulcerative colitis.
CORRECT. Obtaining vital signs every four hours for a client with ulcerative colitis is within the scope of practice for an UAP.
e. Transport a client who is utilizing oxygen and has a peripheral IV catheter.
CORRECT. Transporting a client to surgery with oxygen and a peripheral IV catheter can be assigned to the UAP.
THESE ARE INCORRECT RATIONALE
c. Provide initial food by mouth for a client who has experienced a brain attack.
INCORRECT Providing initial food by mouth for a client who has experienced a brain attack is not an appropriate task to delegate to the UAP. (Initial feedings of a CVA client is a high risk event and can only be done by the RN).
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A nurse is supervising a graduate nurse. The nurse evaluates the client care the graduate nurse provides by doing which of the following?
Select all that apply. |
Select one or more: a. Evaluates the nurse’s goals.
b. Determines if client outcomes were met.
c. Reinforces client education.
d. Provides feedback to the nurse.
e. Intervenes if necessary.
Answer
b. Determines if client outcomes were met.
CORRECT. The supervising nurse will determine if client outcomes were met.
d. Provides feedback to the nurse.
CORRECT. The supervising nurse will provide feedback to the graduate nurse when necessary and appropriate.
e. Intervenes if necessary.
CORRECT. The supervising nurse will intervene as necessary if unsafe clinical practices are identified.
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Two staff members have called in sick on the medical-surgical unit and no additional help is available. The remaining team members consist of an RN, an LPN and unlicensed assistive personnel (UAP). Which of the following should be considered by the nurse when making client assignments? Select all that apply: |
Select one or more: a. Evaluate client needs to determine if assigned nurse can meet plan of care outcomes. b. Evaluate and verify the competency of the health care team. c. Continually provide supervision, either directly or indirectly, to the team. d. Identify what tasks are appropriate to delegate for each specific client. e. Evaluate the health status and complexity of care required by the client. Answer
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A nurse has received an inappropriate assignment. Which of the following actions should the nurse take? Select all that apply. |
Select one or more: a. Accept the assignment and complete tasks as comfortable.
b. Delegate care of the assigned client(s) to another nurse.
c. File an unsafe staffing complaint with the appropriate personnel.
d. Refuse the assignment and report to the nurse manager.
e. Bring the inappropriate assignment to the attention of the charge nurse.
Answer
c. File an unsafe staffing complaint with the appropriate personnel.
An unsafe staffing complaint should be filed with the appropriate personnel if there is no satisfactory resolution of the assignment after reporting it to the charge nurse.
e. Bring the inappropriate assignment to the attention of the charge nurse.
The nurse should bring the inappropriate assignment to the attention of the scheduling/charge nurse and negotiate a new assignment at the beginning of their shift.
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Two staff members have called in sick on the medical-surgical unit and no additional help is available. The remaining team members consist of an RN, an LPN and unlicensed assistive personnel (UAP). Which of the following should be considered by the nurse when making client assignments?
Select all that apply: |
a. Evaluate client needs to determine if assigned nurse can meet plan of care outcomes.
b. Evaluate and verify the competency of the health care team.
c. Continually provide supervision, either directly or indirectly, to the team.
d. Identify what tasks are appropriate to delegate for each specific client.
e. Evaluate the health status and complexity of care required by the client.
Answer
b. Evaluate and verify the competency of the health care team.
CORRECT. Assessing and verifying the competency of the health care team considers the right person being assigned a client that is within their scope of practice.
d. Identify what tasks are appropriate to delegate for each specific client.
CORRECT: Using the five rights of delegation to decide and assign client care formalizes the use of a professional judgment and critical thinking skills. Identify what tasks are appropriate to delegate for each specific client is realizing the right task for the team member.
e. Evaluate the health status and complexity of care required by the client.
CORRECT: Using the five rights of delegation to decide and assign client care formalizes the use of professional judgment and critical thinking skills. Assessing the health status and complexity of care required by the client considers the right circumstance for the team member to deliver effective care. THESE ARE INCORRECT RATIONALE
a. Evaluate client needs to determine if assigned nurse can meet plan of care outcomes. INCORRECT: Evaluating the client needs and determining if the nurse facilitated desired client outcomes is also not an aspect to be considered while assigning client care. This is an evaluative task of the team member caring for the client and the supervisor as they fulfill their supervisor role.
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A nurse is working in the Emergency Department (ED). In which order should the following clients be triaged? |
1. 30-year-old male reporting shortness of breath.
2. 18-year-old male with a possible fractured tibia.
3. 24-year-old female with a swollen and bruised ankle.
4. 40-year-old female with high fever and productive cough.
Select one: a. 2, 4, 3, 1
b. 2, 4, 3, 1
c. 3, 2, 4, 1
d. 1, 4, 2, 3
Answer
d. 1, 4, 2, 3 Correct Sequence--1,4,2,3 Rationales: 1. Shortness of breath is considered an emergent triage category and implies that a condition exists that poses an immediate threat to life or limb. This client would be seen first. 4. High fever and productive cough would raise suspicion of pneumonia. New onset of pneumonia is considered an urgent triage category. This implies that the client should be treated quickly, as long as respiratory failure does not appear imminent. 2. A possible fractured tibia is considered an urgent triage category. This implies that the client should be treated quickly. 3. A swollen and bruised ankle is considered non-urgent. The client can generally wait for several hours without a significant risk of clinical deterioration.
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A nurse is caring for a client experiencing an anaphylactic reaction. List the following interventions the nursing team will take in order beginning with highest priority. |
1. Administer epinephrine IV
2. Teach the client to carry an EpiPen at all times
3. Begin an intravenous infusion with 0.9% sodium chloride
4. Establish a patent airway.
5. Administer diphenhydramine IVP
Select one: a. 2, 4, 5, 1, 3
b. 3, 2, 5, 4, 1
c. 4, 3, 1, 5, 2
d. 5, 3, 2, 4, 1
Answer
c. 4, 3, 1, 5, 2 Airway is always the highest priority if there is the possibility of a compromised airway. An intravenous line will be necessary to administer emergency drugs. Epinephrine is the drug of choice for the treatment of anaphylaxis. The medication is administered every 10 to 15 minutes until the reaction has subsided. Epinephrine is given for its vasoconstrictive action. Benadryl blocks histamine release and reduces capillary permeability. Teaching is important to prevent or treat further reactions, but this will be done after the crisis period is over.
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