● A charge nurse finds an increased incidence of health care associated infections (HAIs)
on a long term care unit. Which priority action should the charge nurse take to address
the problem?
●
● A. monitor the staff's hand hygiene techniques
● B. hold a mandatory in service training session about hand hygiene & infection rates
● C. require nurses to take an online course on HAIs
● D. conduct a chart review to gather data about pts who developed HAIs - ANS - D.
conduct a chart review to gather data about pts who developed HAIs
●
● Rationales..
●
● The charge nurse should first conduct a chart review / audit in order to gather data about
the pts who developed infections. This info will provide the charge nurse w/ potential
indicators / fractos what resulted in the increased incidence of HAIs
● \A charge nurse in an ED is making assignments for an AP during a shift w/ unexpected
staff absences. Which of the following assignments should the charge give to a float AP
from the med surg unit?
●
● A. escorting pts from the ED to other areas of the facility for tests
● B. sitting at the reception desk answering telephones & directing pts
● C. restocking the exam rooms after each pt is discharged
● D. shadowing an AP who is regularly assigned to the ED - ANS - A. escorting pts from
the ED to other areas of the facility for tests
●
● Rationales...
●
● Pts in the ED often require transport to other departments. Typically, transporting stable
pts is a task that may be delegated to an AP, & escorting pts is likely a normal part of the
AP's regular routine
● \A charge nurse is observing a group of newly licensed nurses. Which of the following
actions should the charge nurse report to the nurse manager as a violation of HIPAA?
●
● A. assigning a pt who requested a private room to a semi-private room due to
unavailability
● B. placing a pt who is confused in restraints
● C. talking about pts w/ other nurses in the cafeteria
● D. wheeling a pt who is wearing a sheet down the hall into the shower room - ANS - C.
talking about pts w/ other nurses in the cafeteria
●
,● Rationales..
●
● The nurse should not discuss info about pts
● \A charge nurse is performing a quality-assurance audit on the documentation of several
pts' charts. Which of the following documentation items should the charge nurse ID as a
correct entry in the pt's medical record?
●
● A. the pt appeared angry when family members were visiting
● B. the pt ambulated for 10 min three times during the shift
● C. the pt seemed to be upset about the dx
● D. an incident report was completed when the pt fell at 1000 - ANS - B. the pt ambulated
for 10 min three times during the shift
●
● Rationales..
●
● The charge nurse should ID that this documentation item reflects objective data about
the pt's actions
●
● A. the documentation item is an interpretation of the pt's feelings. The documentation
should use pt quotes about how the pt is feeling whne documenting subjective data
rather than relying on the sures's perception of the pt's emotions
●
● C. the documentation item is an interpretation of the pt's feelings. The documentation
should use pt quotes about how the pt is feeling when documenting subjective data
rather than relying on the nurse's perception of the pt's emotions
●
● D. documentation about the completion of an incident report should never be noted in
the pt's medical records. The nurse can document info about the events surrounding the
incident in the med record (ex. the fall & resulting pt outcomes)
● \A charge nurse is planning a department in-service training session about radioactive
implants for a group of staff nurses. Which of the following points should the charge
nurse include in the presentation? SATA
●
● A. pts should be places in a private room
● B. throw away an implant that has fallen out in the pt's trash can
● C. staff members should wear a dosimeter badge when caring for the pt
● D. pts should be on bed rest
● E. children over the age of yrs can visit if they are accompanied by an adult - ANS - A.
pt's should be placed in a private room
● C. staff members should wear a dosimeter badge when caring for the pt
● D. pt's should be on bed rest
●
● Rationales..
●
,● Pt/s should be placed in a private room to avoid exposing other pt's to radiation from the
implant. The nurse should follow the principles of time, distance, and shielding when
working w/ a pt who is recieving internal radiation therapy.
●
● Health care providers should wear a dosimeter badge. This badge measures & records a
staff member's amount of exposure to radiation. Pt's who have a radioactive implant
should remain on bed rest while the implant is in place to prevent dislodgement.
●
● B. the nurse should pick up a radioactive implant that has fallen out w/ forceps & place it
in a lead container
●
● E. children under the age of 16 yrs & women who are pregnant are prohibited from
visiting a pt who has a radioactive implant
● \A charge nurse is planning an in-service training session about pt advocacy w/ a group
of staff nurses. Which of the following situations should the nurse include as an example
of pt advocacy? SATA
●
● A. discussing tx options w/ a pt who was dx w/ pancreatic cancer
● B. notify the provider when a pt has questions about eh procedure
● C. helping a pt make a lsit of questions to ask the provider
● D. clarifying the dosage of a med prescribed for a pt who has impaired liver function
● E. carrying out the end of life wishes outlined in the living will of an older adult pt who
has end stage renal disease - ANS - B. notifying the provider when a pt has questions
about the procedure
● C. helping a pt make a list of questions to ask the provider
● D. clarifying the dosage of a med prescribed for a pt who has impaired liver function
● E. carrying out the end of life wishes outlined in the living will of an older adult who has
end stage renal disease
●
● Rationales..
●
● As a pt advocate, the nurse should make sure pts have all thier questions answered &
possess the info needed to make an informed decision. Clarifying the dosage of a med
prescribed for a pt who impaired liver function can prevent med toxicity & demonstrates
pt advocacy. Carrying out the end-of-life wishes of a pt who has end-stage renal disease
demonstrates pt advocacy
● \A charge nurse is providing teaching to a new staff nurse about the management of a
team consisting of a LPN & an AP. Which of the following pieces of info should the
charge nurse include in the teaching?
●
● A. the LPN can delegate the task of teaching a pt about foot care to the AP
● B. the LPN should be familiar w/ the task she plans to delegate
● C. the person who accepts the delegated task also assumes accountability for the task
, ● D. the LPN can delegate an initial assessment of a pt to the LPN - ANS - B. the LPN
should be familiar w/ the task she plans to delegate
●
● Rationales..
●
● The nurse should be familiar w/ the task she plans to delegate so she can define the
task as well as the expectation of its completed status, monitor the performance of the
task, and provide feedback regarding the performance
●
● A. the nurse should not delegate the task of teaching a pt about foot care, as this task is
not w/in the scope of practice for an AP
●
● C. while the person who accepts the delegated task assumes the responsibility for the
task, accountability for any delegated task remains w/ the nurse who delegated it
●
● D. It is the responsibility of the RN to complete the initial assessment of a pt admitted to
a nursing unit
● \A charge nurse on a med surg unit is assigning pt care to the upcoming shift. Which of
the following tasks should the nurse delegate to an AP? SATA
●
● A. performing colostomy care
● B. measuring a pt's intake & output
● C. interpreting a pt's lab values following surgery
● D. providing postmortem care to a pt
● E. checking nasogastric tube patency - ANS - B. measuring a pt's intake & output
● D. providing postmortem care to a pt
●
● Rationales..
●
● Measuring the intake & output of a pt & providing postmortem care are w/in the range of
function for an AP
●
● A. performing colostomy care involves data collection, which is outside the range of
function for an AP this tasks should be delegated to a LPN
●
● C. Interpreting a pt's lab values following surgery involves data collection & is outside the
range of function for an AP this tasks should be delegated to an LPN
●
● E. checking nasogastric tube patency should be delegated to an LPN not an AP
● \A charge nurse on a med surg unit is making assignments for the oncoming shift. Which
of the following pts should the charge nurse assign to a LPN?
●
● A. a pt who requires an updated plan of care following a dx of cancer
● B. a pt who is postop following a total hip replacement & requires discharge teaching
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