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What can be delegated to Assistive personnel (AP)?
- ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow precautions) - positioning - bed making
- specimen collection - I&O - VS (stable clients A nurse on a med surg unit has received change of shift report and will care for 4 clients. Which of the following clients’ needs will the nurse assign to an AP? ✓ 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: ✓ The client ambulates with his slippers on over his anti-embolic stockings ✓ The client uses a front wheeled walker when ambulating ✓ 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? ✓ Replacing the cartridge and tubing on a PCA pump A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation? Select all: ✓ Right supervision/evaluation ✓ Right direction/communication ✓ Right circumstances A nurse manager of a med surg 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? ✓ 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 one’s own personal decisions, even though those decisions might not be in the person’s best interest ✓ Autonomy What are positive actions to help others? Beneficence 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?
✓ Autonomy 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? Beneficence 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? - 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? Non-maleficence Which of the following situations can be identified as an ethical dilemma? ✓ 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 settings Democratic 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 necessary Laissez 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 situation The 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
✓ Avoid abrupt changes in posture. 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? ✓ 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 ✓ 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? ✓ Wear sunscreen and a hat when outdoors." After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone. Which of the following nursing diagnoses would be a priority to include in his care plan? ✓ Alteration in skin integrity related to decrease in tissue oxygenation. A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be restricted in the client's diet? ✓ Protein. An extremely agitated client is receiving haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. The MOST important nursing intervention is to ✓ monitor vital signs, especially blood pressure, every 30 minutes. The nurse is caring for clients in the skilled nursing facility. Which of the following clients require the nurse's IMMEDIATE attention? ✓ A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired two days ago. The nurse is observing care given to a client experiencing severe to panic levels of anxiety. The nurse would intervene in which of the following situations? ✓ The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety. A 69-year-old client is undergoing his second exchange of intermittentperitoneal dialysis (IPD). Which of the following would require an intervention by the nurse? ✓ The dialysate outflow is cloudy. The clinic nurse is performing diet teaching with a 67-year-old client with acute gout. The nurse should teach the client to limit his intake of ✓ red meat and shellfish. A client is scheduled for a left lower lobectomy. The physician has ordered diazepam (Valium) 2 mg IM for anxiety. The nurse would determine that the medication is appropriate if the client displays which of the following symptoms?
✓ Restlessness and increased heart rate. A 59-year-old woman with bipolar disorder is receiving haloperidol (Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST? ✓ You are experiencing a side effect of Haldol." The physician orders ranitidine hydrochloride (Zantac) 150 mg PO qd for a client. The nurse should advise the client the BEST time to take this medication is. ✓ at hs. If a client develops cor pulmonale (right-sided heart failure), the nurse would expect to observe ✓ peripheral edema and anorexia. The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST? ✓ A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the place and time. The nurse in the outpatient clinic teaches a client with a sprained right ankle to walk with a cane. What behavior, if demonstrated by the client, would indicate that teaching was effective? ✓ The client holds the cane in her left hand. A client returns to his room following a myelogram. The nursing care plan should include which of the following? ✓ Encourage oral fluid intake. The nurse is caring for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST? ✓ "Take three deep breaths, hold your incision, and then cough." A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder? ✓ "I don't know who I am and I don't know where I live." A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY? ✓ Decreased level of consciousness. The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to care for ✓ a client with Alzheimer's requiring assistance with feeding. An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include that the client ✓ cough and deep breathe.
The patient's albumin level is 4.0mg/dL. A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication? ✓ The client's urine test is positive for glucose and acetone. After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate? ✓ Aspirate the gastric contents with a syringe. After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician? ✓ There is clear fluid draining from the client's right ear. The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions? ✓ Serve the meal to the client in the seclusion room. A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate? ✓ Administer naloxone (Narcan). What type of infectious diseases are required to be reported to the health department? ✓ severe cases of Staphylococcus aureus infections including methicillin-resistant Staphylococcus aureus (MRSA) What is the process of taking a telephone order from a provider? Patient name, drug, dose, route, frequency read back for accuracy A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA a) Place the client in a negative pressure room b) wear gloves when assisting the client with oral care e) Use antimicrobial sanitizer for hand hygiene A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? ✓ have family members wear a gown and gloves when visiting A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next? ✓ place a warm compress over the IV site A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client? ✓ use a bed exit alarm system
A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action? ✓ implement a regular toileting schedule Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client? ✓ apply intermittent suction when withdrawing the catheter A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence? ✓ instruct the client to focus on gradually resuming self-care tasks A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding? ✓ serum albumin level of 3 g/dL A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure? ✓ "I flushed what I urinated at 7 am and have saved the rest since" A nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance? ✓ 0.9% sodium chloride A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching? ✓ maintain two points of support on the floor Which of the following should indicate to a nurse the need to suction a client's tracheostomy? ✓ Irritability A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? ✓ cleanse the wound from the center outwards A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid? ✓ orange sherbet A nurse is caring for a client who is having difficulty voiding following the removal in an indwelling urinary catheter. Which of the following interventions should the nurse take? ✓ pour warm water over the clients perineum When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? ✓ Prescription drug intoxication.
A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? (Select all that apply.) ✓ Nail polish should not be used near a client who is receiving oxygen. ✓ A "No Smoking" sign should be placed on the front door. ✓ A fire extinguisher should be readily available in the home. A nurse is providing home safety instructions to a group of older adult clients. Match the safety risk with the appropriate instruction. c Passive smoking: Avoid enclosed areas with others who may be smoking. _a Carbon monoxide poisoning: Have water heaters inspected on an annual basis. b Food poisoning: Cook all meat at an appropriate temperature. When performing nasotracheal suctioning what technique should be used? Sterile asepsis bc the trachea is considered sterile and prevents infections A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following?
- Hypotension What do you do when a client has a seizure?
- lower to bed/floor
- protect head, move nearby furniture, provide privacy, - - put on side with head flexed slightly forward, and loosen clothing to prevent injury
- in event of seizure, stay with client and call for help
- admin meds as ordered
- note duration of seizure and sequence and type of movement Seclusion and restraints
- must be ordered
- should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient
- a client may voluntarily request temp seclusion
- restraints can be physical or chemical
- if used, frequency of client assessments in regards to food, fluid, comfort, and safety should be performed and documented every 15-30 min What position is good to use for a patient who is at high risk for a pressure ulcer
- 30 degree lateral position is recommended for clients at risk for pressure ulcers Health promotion (injury prevention-suffocation): infant (birth-1 yr)
- avoid plastic bags
- keep balloons out of reach
- ensure crib mattress fits snugly
- ensure crib slats are no more than 6 cm (2.4 in) apart
- remove crib mobiles and gyms by 4-5 months
- do not use pillows in crib
- place infant on back for sleep
- keep toys with small parts out of reach
- remove drawstrings from jackets and other clothing Hypotension is classified with a reading below normal;
- systolic < 90 mm Hg; can be a result of fluid depletion, heart failure, or vasodilation What temperature should pork be cooked at: 160 degrees What is the safest way to thaw out frozen foods: In the refrigerator What are the precautions for vancomycin resistant enterococcus: Standard precautions including hand washing and gloving should be followed What does a newborns poop look like: If your baby is exclusively breastfed, her poop will be yellow or slightly green and have a mushy or creamy consistency? What is appropriate for an adolescent in the hospital?
- Puzzles and books What is the proper nutrition during pregnancy?
- Folic acid is important for pregnancy, as it can help to prevent birth defects known as neural tube defects, including spina bifida
- green leafy vegetables and brown rice What should be avoided during pregnancy?
- Do not take vitamin A supplements, or any supplements containing vitamin A (retinol), as too much could harm your baby What is the most appropriate method for contraception for an adolescent: IUD or implant If a patient has anorexia nervosa and works out constantly: Allow them to work out and continue their regimen What medications can be taken to help with smoking cessation?
- Bupropion hydrochloride is a medicine for depression, but it also helps people quit smoking. Brand names include Zyban®, Wellbutrin®, Wellbutrin SR® and Wellbutrin XL® but this medication is also available as a generic. Varenicline (chantix) What are the five stages of grief
- Denial
- Anger
- Bargaining
- depression
- acceptance discrete and applies the letting go of an object or person before the loss as in the case of terminal illness individuals have the opportunity to greet before the actual loss: anticipatory grief Involves difficult progression through the expected stages of the grieving process grief work is prolonged and manifestations more severe. client may develop suicidal ideation, intense feelings of guilt and lowered self-esteem. somatic complaints persist for an extended period of time: dysfunctional grief Signs for meningococcemia: Vomiting, febrile, petechial rash (unstable) Levothyroxine effects: Used to restore client's metabolic rate
- Toxic effects = heat intolerance, Tachycardia, Weight loss, Hypertension Multiple Sclerosis Patient:
Case Management nursing involves:
*Decreasing cost by improving client outcomes
- Providing education to optimize health participation
- Advocating for services + client's rights What is bipolar disorder? Bipolar disorder is a mood disorder with recurrent episodes of depression and mania. What comorbidities may be observed with a patient who is bipolar? Substance use disorder (experiences more rapid cycling), anxiety disorders, eating disorders, ADHD. What therapy will be useful for patients with bipolar? Electroconvulsive therapy for the patient who is suicidal or rapid cycling who HAS taken Lithium and has proven ineffective. Used to subdue manic behavior. What kind of medications are indicated for abstinence maintenance of alcohol?
- Disulfiram (Antabuse), Naltrexone (Vivitrol), Acamprosate (Campral)
- Teaching points for naltrexone (Vivitrol)?
- Take with meals to supress GI distress. Monthly IM injections should be suggested for patients who have difficulty to adhering to the medication regimen. A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
- drink liquids only between meals. A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient? ✓ Suggest fluid intake of at least 2 L per day A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? ✓ Right lower quadrant Which outcome indicates effective client teaching to prevent constipation? ✓ The client reports engaging in a regular exercise regimen. Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? ✓ Hypotension The nurse is assessing a client with a bleeding gastric ulcer. When examining the client's stool, which of the following characteristics would the nurse be most likely to find? ✓ Black and tarry appearance
