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 surge unit has recieved change of shift report
and will care f...
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- ADLs - bathing - grooming - dressing - ambulating - feeding
What can be delegated to Assistive personnel (AP)? (w/o swallow precautions) - 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?
A. Feeding a client who was admitted 24 hours ago with aspiration
pneumonia
C
B. Reinforcing teaching with a client who is learning to walk with
a quad cane
C. Reapplying a condom catheter for a client who has urinary
incontinence
D. Applying a sterile dressing to a pressure ulcer
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:
A. the roommate is up independently B
B. The client ambulates with his slippers on over his antiembolic C
stockings D
C. The client uses a front wheeled walker when ambulating
D. The client had pain meds 30 minutes ago
E. The client is allergic to codeine
F. the client ate 50 % of his breakfast this morning
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?
A. Assisting a client who is 24 hr postop to use an incentive
spirometer
D
B. Collecting a clean catch urine specimen from a client who was
admitted on the previous shift
C. providing nasopharyngeal suctioning for a client who has pneu-
monia
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 pre-
senting the 5 rights of delegation. Select all:
B
A. Right client
C
B. Right supervision/evaluation
E
C. Right direction/communication
D. Right time
E. Right circumstances
A nurse manager of a med surge unit is assigning care respon-
sibilities 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
A. Charge nurse
B. RN
C. LVN
D. AP
What is the study of conduct and character? Ethics
What are the values and beliefs that guide behavior and decision
Morals
making?
What is the right to make ones own personal decisions, even tho
Autonomy
those decisions might not be in the persons best interest
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
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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 princi-
ples?
A
A. Fidelity
B. Autonomy
C. Justice
D. Nonmalificience
A nurse offers pain meds to a client who is postop prior to ambu-
lation. The nurse understands that this aspect of care delivery is
an example of which of the following ethical principles?
A. Fidelity D
B. Autonomy
C. Justice
D. Beneficience
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 trans-
plant have to meet the same qualifications, the students should
understand that this aspect of care delivery is an example of which
C
ethical principle
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence
A nurse questions a med prescription as too extreme and light of
the clients advanced age and unstable status. The nurse under-
stands that this action is an example of which ethical principle
A. Fidelity D
B. Autonomy
C. Justice
D. Nonmalificence
Which of the following situations can be identified as an ethical
dilemma?
A. A nurse on a med surge unit demonstrates signs of chemical
impairment
B. A nurse over hears another nurse telling an older adult client
C
that if he doesnt stay in bed she will restrain him
C. A family has conflicting feelings about the initiation of enteral
tube feedings of their father who is terminally ill
D. A client who is terminally ill hesitates to name her spouse on
her durable power of attorney form
Most managers can be categorized as authoritative, democratic, and laissez faire
makes decisions of the group
motivates by coercion
communication occurs down the chain of command Authoritative
Work output by the staff is usually high-good for crisis situations
and bureaucratic settings
includes the group when decisions are made
Motivates by supporting star achievements
Communication occurs up and down the chain of command Democratic
Work output by staff is usually of good quality-good when coop-
eration and collaboration is necessary
makes very few decisions and does little planning
motivation is largely the responsibility of individuals staff mem-
bers Laissez faire
Communication occurs up and down the chain of command and
between group members
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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
- Physiological needs first (oxygen, shelter, food)
- Safety & security needs (physical safety)
The nurse should consider the hierarchy of human needs when
- Love and belonging
prioritizing interventions, which are?
- Self esteem
- Self actualization
Airway
The ABC framework identifies, in order, the three basic needs for
Breathing
sustaining life
Circulation
Nurses must follow what code of standards in delegating and
ANA codes of standards
assigning tasks
- caring
- autonomy
What values would a nurse possess to be a client advocate?
- respect
- empowerment
What do the nurse need to keep in mind about the client when
Client's religion & culture
being their advocate?
When should planning discharge process begin?
a. at time of admission
b. 2 days after client is admitted A
c. whenever the nurse has the time to do planning
d. when the physician has the discharge order
What is an interdisciplinary team? A group of health care professionals from different disciplines
Fill in the blank:
1. _______ is used by interdisciplinary team to make health
care decisions about clients with multiple problems. 2. ________,
1 & 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.
- knowledge of nursing care & its management
What is the nurse's contribution to an interdisciplinary team? - 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 2
increase in intracranial pressure?
1. Positive Babinski.
2. High-pitched cry.
3. Bulging posterior fontanelle.
4. Pinpoint pupils.
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
1. A significant increase in pulse rate.
2. A decrease in diastolic blood pressure.
3. Temperature in excess of 98.6°F (37°C).
4. Urine output of at least 30 cc per hour.
The client is exhibiting symptoms of myxedema. The nursing
assessment should reveal
1. increased pulse rate.
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