Nursing Care Management: Delegation, Prioritization, and Client Stability, Exams of Health sciences

Download Nursing Care Management: Delegation, Prioritization, and Client Stability and more Exams Health sciences in PDF only on Docsity! 1 [Date] HURST REVIEW MANAGEMENT OF CARE 116 Questions and Answers Latest Updated 2024 Test 1. As a new nurse, you cannot provide safe care to your clients if you don't know how to - Correct answer -manage care -assign care -supervise care -prioritize care 2. The judgments you make in management situations have to be based on - Correct answer med-surg knowledge 3. If you don't understand disease processes, you cannot - Correct answer set priorities of care or determine which staff member would be best to take care of the client 4. You MUST know your _______________________, and then you can move on to ________________________ - Correct answer core content; management decisions 5. Assignments include - Correct answer the routine care, activities, and procedures that are within the authorized scope of 2 [Date] practice of the RN, LPN/LVN, or part of the routine functions of the UAP 6. Assignment is the sharing of - Correct answer routine work that each staff member is responsible for during a given shift or work period 7. The assigned tasks should be part of - Correct answer the course work taught in the basic educational program of the staff member 8. Delegation is - Correct answer allowing a specific task to be performed that is not routinely performed and is BEYOND the traditional role of the individual to which the nursing activity skill, or procedure is delegated 9. The key is that the staff member who is delegated the task has - Correct answer received additional training or education and has validated competency to perform the delegated task 10. You can delegate the responsibility of the task, but you cannot - Correct answer delegate the ultimate accountability 5 [Date] 32. The Right Task: Can the UAP assist the client to the bathroom with a walker? - Correct answer yes 33. The Right Task: Can the UAP perform a fleet enema? - Correct answer no, because this is a medicated procedure 34. The Right Task: Can the UAP answer the client's call light? - Correct answer yes 35. The Right Task: Can the UAP clean and sanitize the client's room? - Correct answer yes 36. The Right Task: Can the UAP change the linen on a totally bedridden client? - Correct answer yes 37. The Right Task: Can the UAP provide mouth care and denture cleansing? - Correct answer yes 38. The Right Task: UAPs CAN'T do - Correct answer medications 6 [Date] 39. The Right Task: What tasks can the LPN perform? - Correct answer -data collection 40. -NO assessment 41. -updating client data 42. -NO evaluation (involves assessment) 43. -NO admission hx 44. The Right Task: The RN NEVER delegates or assigns tasks that involve - Correct answer assessment 45. The Right Task: The LPN can assist the RN in data collection, but that is NOT - Correct answer assessment in the NCLEX world 46. The Right Task: After the initial assessment, the LPN - Correct answer updates client data 47. The Right Task: Can the LPN evaluate the client to determine if a goal has been met? - Correct answer no 48. The Right Task: The LPN cannot do any form of _____________________, because _________________________________ - Correct answer 7 [Date] evaluation; evaluation involves assessment, and we NEVER assign or delegate assessment or judgment 49. The Right Task: Who must do the admission history? - Correct answer the RN 50. The Right Task: If someone else, such as an LPN, collects the admission data for you, NEVER - Correct answer sign off on the form until you have validated the data 51. The Right Task: Can the LPN implement tasks on the plan of care? - Correct answer yes 52. The Right Task: Can a LPN devise a teaching plan for a newly diagnosed diabetic? - Correct answer no, ONLY the RN can plan care 53. The Right Task: LPNs can do teaching, but - Correct answer it's basic standardized teaching or reinforcing teaching 54. The Right Task: Can the LPN data collect, monitor and observe? - Correct answer yes 10 [Date] __________________________ - Correct answer FIRST; responsibility or priority 70. The Right Task: Is the diabetic client with low blood sugar stable or unstable? - Correct answer unstable 71. The Right Task: Is the client returning from an invasive procedure stable or unstable? - Correct answer unstable 72. The Right Task: Is the client with neurological problems, stable VS, no change in LOC/neuro checks stable or unstable? - Correct answer stable 73. The Right Task: Is the client with acid-base imbalance and respiratory distress with unstable VS stable or unstable? - Correct answer unstable 74. The Right Task: Is the client with chronic HTN, hx of angina controlled with meds and living alone stable or unstable? - Correct answer stable 11 [Date] 75. The Right Task: Is the client with HIV+, medication compliance and working full time stable or unstable? - Correct answer stable 76. The Right Task: Acid-base imbalance makes a client - Correct answer unstable 99% of the time 77. The Right Task: Can the LPN perform any tasks in an unstable situation? - Correct answer yes! they can help the RN by taking BP, getting a crash cart, etc 78. The Right Circumstance: First, the right circumstance could be influenced by the - Correct answer work setting 79. The Right Circumstance: LPNs and RNs function in different roles depending on - Correct answer the work place 80. The Right Circumstance: Another factor that influences the right circumstance is - Correct answer a change in the client status from stable to unstable 12 [Date] 81. The Right Circumstance: Client conditions can change and the LPN or UAP must - Correct answer report this to the RN (RN should reassess right away) 82. The Right Circumstance: If you're unsure if the UAP can perform a procedure, - Correct answer go with them yourself and make sure no harm is done 83. The Right Circumstance: When staff members are pulled to a new floor, you should - Correct answer pretend they are a brand new nurse all over again 84. The Right Circumstance: Do not give a nurse from another floor any clients requiring - Correct answer specialized care 85. The Right Circumstance: Routine task assignments can change based on - Correct answer the circumstance 86. The Right Circumstance: The same activity may - Correct answer differ in each situation 15 [Date] 98. Right Direction and Communication: Tell what you want done ___________, and what you want done in a __________________________ - Correct answer first; particular time frame 99. Right Direction and Communication: Provide specific directions and expectations of how you want the task to be performed and - Correct answer describe the findings you want to be reported 100. Right Supervision and Evaluation or Feedback: You must _____________, ____________, and ____________________ the carrying out of any delegated task - Correct answer guide; supervise; evaluate 101. Right Supervision and Evaluation or Feedback: You must follow up to - Correct answer see that the nursing tasks that you delegated are done properly 102. Right Supervision and Evaluation or Feedback: We need to ask these 3 questions after a delegated task is completed - Correct answer 1. was the task done properly & in a safe manner? 103. 2. was the task done in the proper time frame? 104. 3. were the client's needs met? 16 [Date] 105. Right Supervision and Evaluation or Feedback: When a task is performed and you identify a weakness, you are supposed to - Correct answer teach, teach, teach 106. Transferring Care Between RNs: RN to RN transfer of care is called - Correct answer a handoff and transfers BOTH responsibility and accountability 107. Priorities of Care: Priority questions are considered - Correct answer management of care 108. Priorities of Care: You will go see all of the clients, but you have to - Correct answer set priorities and go see the one who has the most life-threatening condition first 109. Privacy: We are responsible for keeping all client information - Correct answer confidential 110. Privacy: You CANNOT post pictures of your client on - Correct answer social media 17 [Date] 111. Privacy: Social media posts violate the clients' - Correct answer right to privacy 112. Privacy: Violations infringe on ____________________________ and could lead to _______________________________________ - Correct answer federal privacy laws; job loss, action by the board of nursing, or even the loss of your license 113. Privacy: You are the client ________________ and are responsible for _________________________________________ - Correct answer advocate; making sure that client privacy and confidentiality are maintained 114. Privacy: Confidentiality and privacy should be maintained with - Correct answer conversations, electronic records, or any sources of client information 115. Privacy: You can NOT access a client's record that - Correct answer you are not responsible for providing care to 116. Organ Donation: Organ donation decision made by a minor can be - Correct answer refused by the family, regardless of presence of documentation of organ donation wishes by the client 20 [Date] need to complete this task before breakfast but it is not the first priority of the morning. 133. Incorrect: It will be important to get the day room ready for group breakfast. However, preparing the dayroom will likely take quite a bit of time and there is a more important task that needs yo be completed prior to breakfast preparations. 134. Review pages 262 and 269 of your student book if you missed this question. 135. A nurse is hired to address quality improvement at a long- term care facility. The nurse quickly notes several legal issues requiring intervention and correction. What situation noted by the nurse represents the greatest legal or ethical risk in the facility? 136. Choose One 137. A LPN regularly leaves pills in client's room for client to take after meals. 138. The UAP refills the water pitcher for a client on fluid restrictions. 139. Staff asks family members to assist in turning an obese client. 140. The UAP loosens trach ties at bath-time to apply cream on neck. - Correct answer 1. CORRECT. All the situations have the potential to become problematic. However, leaving medications unattended in a client's room violates multiple protocols as well as legal issues. The nurse must witness the client actually ingesting medication to legally sign off the drug as 'given'. Also the nurse should observe the client in case of accidental choking. Unattended pills could easily be ingested by someone 21 [Date] other than the designated individual, or the client may simply throw the medication away. 141. 2. INCORRECT. All staff should have been clearly instructed regarding the client's fluid restrictions. However, filling the pitcher does not necessarily mean the client drank the extra fluid. The nurse is responsible to instruct staff on any type of client restrictions. A sign noting fluid restrictions could be placed above the bed without violating HIPAA regulations as long as no name appears on the sign. 142. INCORRECT. Regardless of whether a client is obese, family should never be asked to assist staff in moving or positioning an individual. Family is neither properly trained nor covered by facility insurance for personal injury. Even if family offers to assist, the staff should utilize only other staff members. 143. INCORRECT. The UAP is never permitted to untie or loosen trach ties for any reason. If the client needs, or requests, cream to the neck area, the RN can do so during trach care. If the back of the client's neck is irritated, the RN can also address that issue with proper interventions. 144. Review pages 262-263 if you missed this question. 145. An RN has delegated several tasks to be completed before end of shift. What delegation "right" was violated by the nurse? 146. Select All That Apply 147. LPN asked to obtain stat vital signs on client reporting chest pain. 148. UAP asked to remove foley catheter prior to client discharge. 149. UAP assigned to empty and measure fluid in client urinal. 22 [Date] 150. LPN instructed to check drainage in client's closed drainage unit (CDU) for amount. 151. UAP ordered to obtain finger-stick blood sugar on client at four pm. - Correct answer 1, 2, 4, and 5. CORRECT. The rights of delegation include the right task, right circumstances, right person and the right direction followed by the right supervision or evaluation. The RN has made several errors in utilizing correct delegation principles. A client reporting chest pain is considered unstable and should not be assigned to the LPN, even for vitals. Removal of invasive lines cannot be assigned to a UAP, which includes removal of a foley catheter. Chest tube drainage should be evaluated by an RN in order to assess color, consistency and amount during the shift. Blood glucose levels obtained by Accu- check, also referred to as finger stick, can not be performed by a UAP and reported to the LPN or RN. 152. 3. INCORRECT. The UAP is qualified to empty a urinal or bedpan as part of assisting clients with ADL's and can also measure the amount of fluid at that time. Both task and individual meet the correct "rights" of delegation. 153. The charge nurse on a surgical unit is assigning tasks to an LPN float nurse. What client(s) would be most appropriate for the LPN? 154. Select All That Apply 155. Client with Gardner-Wells tongs scheduled for pin care. 156. Client needing straight-cathed for a stat urine sample. 157. Client to be ambulated following open cholecystectomy. 158. Client requiring sterile dressing change to left wrist burn. 25 [Date] 176. Reinforce teaching for a client awaiting discharge. 177. Feed pureed food to client with left-sided paralysis. 178. Get finger stick on confused client with diaphoresis. 179. Provide ice packs to client with a new long leg cast. 180. Submit - Correct answer 2, 3, and 4. CORRECT. Unlicensed assistive personnel, often referred to as a 'nursing assistant', should be assigned repetitive, uncomplicated tasks on stable clients. These tasks include activities of daily living, routine vital signs and ambulation. The UAP is not able to reinforce teaching because this requires an evaluation of client learning. The client with left-sided paralysis is at risk for aspiration and requires specific knowledge about position during feeding. An LPN or RN should be assigned to feed this client. Getting a blood sugar by finger-stick is not within the abilities of a UAP across the country. Some states allow FSBS by UAPs that have been trained, but this is not from coast to coast. 181. INCORRECT. Obtaining vitals on a post-procedure client is based on the type of test and potential for complications. A colonoscopy is generally an uncomplicated procedure and the UAP would certainly be able to do vitals on this client. 182. INCORRECT. Filling and providing ice packs to a client with a cast is within the scope of activities for unlicensed assistive personnel. The nurse would need to provide instruction about placing ice packs to the side of the cast, rather than on top, but this activity can definitely be assigned to the UAP. 183. Review page 263 of your student book if you missed this question. 26 [Date] 184. The charge nurse is assigning several immediate tasks to on- coming shift personnel. What task should the nurse assign to a licensed nurse only? 185. Choose One 186. Reposition a client with a long term Peg tube. 187. Obtain scheduled vital signs during blood transfusion. 188. Assist diabetic client with neuropathy to walk to bathroom. 189. Ambulate client following laparoscopic appendectomy. 190. Submit - Correct answer 2. CORRECT. Blood transfusions present a potential for complications the entire time the blood is transfusing, even though any problems which might occur generally happen in the first 15 minutes. But data collection regarding client response, including skin color, respiratory status and IV site should be assessed during vitals sign monitoring. 191. INCORRECT. Repositioning a client with a Peg tube can be safely accomplished by unlicensed assistive personnel. A Peg tube is secured inside the stomach wall and simply repositioning a client would not create an issue requiring a nurse. 192. INCORRECT. Ambulating a diabetic client requires the same precautions as walking with any individual. Neuropathy may cause pain or numbness to the soles of the client's feet, but the UAP is still capable of ambulating this client safely. A licensed nurse is not required at this time. 193. INCORRECT. A laparoscopy is the process of performing a surgical procedure without cutting open the body. Three or four small holes are created through which instruments are passed, including a camera, allowing the surgery to be completed. Ambulating this client is no different than any other post- operative walk, and therefore can easily be accomplished by the UAP. 27 [Date] 194. Review pages 264-265 of your student book if you missed this question. 195. A competent elderly client is admitted with a diagnosis of malnutrition following a 30-pound (13.6 kg) weight loss in a month. The family requests insertion of Peg tube for enteral feedings, despite the client's advanced directives indicating "no life-prolonging measures". What is the most appropriate comment by the nurse to the family? 196. Choose One 197. "Perhaps you could convince your parent to allow a Peg tube insertion." 198. "Maybe the client just needs family to prepare meals and help feed the client." 199. "The client completed an advanced directive form specifying what we may do." 200. "It is the client's right to refuse procedures not wanted." 201. Submit - Correct answer 3. CORRECT. This statement by the nurse provides an explanation of advanced directives as well as the fact the client has completed such a form. The focus is placed on the purpose of advanced directives and how medical personal must abide by the client's wishes. The nurse has given the family a response which includes accurate knowledge as well as advocating for the client. 202. INCORRECT. Such a statement does not focus on the client's right to refuse life-extending procedures as noted in the advanced directives. The family is given false hope rather than a correct explanation regarding advanced directives and client rights. 30 [Date] 221. Secretary copying client charts leaves several pages in office copier. - Correct answer 2. CORRECT. Client confidentiality and privacy are guaranteed by both federal and state regulations as well as those principles outlined in the nurse's code of ethics. As a client advocate, the nurse has the responsibility to protect those rights by reporting infractions to the appropriate personnel. An actual violation has occurred when students enter a client's room to observe a procedure without first asking the client's permission. Even though the client is in a teaching hospital, this does not eliminate the client's right to privacy or to refuse to have students present. 222. INCORRECT. Opened and unattended charts represent the potential for confidential information to be viewed by others, including non-medical persons. The potential exists for client information to be seen or used by those not entitled to view such information. Charts should remain closed when not in use. 223. INCORRECT. Such a breach of ethics violates multiple healthcare principles. However, though unprofessional and rude, the staff did not mention a client name or room number. That does not mean there will be no disciplinary action, but actual client details were not revealed. 224. INCORRECT. Leaving client data in a copier violates client privacy and a potential breach of confidentiality. The copy machine is in facility office, not a public location; however, there are individuals within an office which should not have access to those client records. 225. Review pages 269 of your student book if you missed this question. 31 [Date] 226. A competent elderly client is admitted with a diagnosis of malnutrition following a 30-pound (13.6 kg) weight loss in a month. The family requests insertion of Peg tube for enteral feedings, despite the client's advanced directives indicating "no life-prolonging measures". What is the most appropriate comment by the nurse to the family? 227. "Perhaps you could convince your parent to allow a Peg tube insertion." 228. "Maybe the client just needs family to prepare meals and help feed the client." 229. "The client completed an advanced directive form specifying what we may do." 230. "It is the client's right to refuse procedures not wanted." - Correct answer 3. CORRECT. This statement by the nurse provides an explanation of advanced directives as well as the fact the client has completed such a form. The focus is placed on the purpose of advanced directives and how medical personal must abide by the client's wishes. The nurse has given the family a response which includes accurate knowledge as well as advocating for the client. 231. INCORRECT. Such a statement does not focus on the client's right to refuse life-extending procedures as noted in the advanced directives. The family is given false hope rather than a correct explanation regarding advanced directives and client rights. 232. INCORRECT. The nurse is attempting to refocus the family on the client's weight loss rather than the client's choices. The issue at this time is not the cause of the weight loss, but rather the client's right to refuse life-extending procedures as detailed in the advanced directives. 32 [Date] 233. INCORRECT. Though this statement is accurate, it is abrupt and closed-ended. When addressing family, the nurse needs to remember that stress, fear and frustration can overwhelm judgment. The family may fear losing the client and the nurse's statement would not address those fears or the advanced directives. 234. Review page 272 of your student book if you missed this question.