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Nursing Delegation and Client Care Prioritization, Exams of Nursing

Various aspects of nursing delegation and client care prioritization. It discusses the considerations nurses should make when delegating tasks, the types of tasks that can be delegated to licensed practical nurses (lpns) and nursing assistants, the five rights of delegation, and the appropriate actions to take when observing a coworker's concerning behavior. The document also covers the importance of ethical principles in client care, the steps nurses should take when meeting with a client for the first time, and the priority setting frameworks nurses should use to prioritize client assessments. Additionally, it provides examples of nursing standards of practice and accountability, as well as guidance on delegating tasks during client discharge and prioritizing client care when the nurse is assigned a group of clients.

Typology: Exams

2023/2024

Available from 08/28/2024

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Download Nursing Delegation and Client Care Prioritization and more Exams Nursing in PDF only on Docsity! 1 / 94 Nursing 1 Exam 3 Latest Updated Questions with Correct Answers 1.After change of shift report, the nurse is assigned to the following clients. Which client should the nurse assess first? A. 68 year old pt on a ventilator for whom a sterile sputum specimen must be sent to the lab B. 57 year old pt with COPD with a pulse ox reading 90% on the previous shift C. 72 year old pt with pneumonia who needs to be started on IV antibiotics D. 51 year old pt with asthma who reports SOB after bronchodilator inhaler: D. 51 year old pt with asthma who reports SOB after bronchodilator inhaler 2.A nurse is caring for a pt who has peripheral artery disease. Which of the following findings should the nurse report to the provider immediately? A. Report of intermittent claudication B. Shiny, hairless lower extremities C. Absent dorsalis pedis pulse D. Dependent rubor: C. Absent dorsalis pedis pulse 3.The nurse is working in the triage area of an ER and the following 4 clients approach the triage desk at the same time. List the order the nurse will assess them. A. An ambulatory, dazed 25 year old man with a bandaged head wound B. An irritable newborn with fever, petechia, and nuchal rigidity C. A 35 year old jogger with a twisted ankle who has a pedal pulse and no deformity 2 / 94 D. A 50 year old woman with moderate abdominal pain and occasional vomit- ing: B (could be meningitis) A (neurological problem) D C 4.A 56 year old pt comes to the triage area with left-sided chest pain, diaphore- sis, and dizziness. What is the priority action? A. Initiate continuous electrocardiographic monitoring B. Notify the emergency department health care provider C. Administer oxygen via nasal cannula D. Draw blood and establish IV access: C. Administer oxygen via nasal cannula 5.The nurse just received change of shift report on the following pts. Which one will the nurse assess first? A. 26 year old with heart failure caused by congenital mitral stenosis who is scheduled for balloon valvuloplasty later today B. 45 year old with constructive cardiomyopathy who developed acute dysp- nea and agitation 1 hour before the shift change C. 56 year old who underwent coronary angioplasty and stent placement yesterday and has reported occasional chest pain since the procedure D. 77: B. 45 year old with constructive cardiomyopathy who developed acute dysp- nea and agitation 1 hour before the shift change 6.A RN who has been working in labor and delivery has been reassigned to a step-down telemetry unit. Which client would reflect the most appropriate assignment for this nurse? 1. Client who had undergone cardioversion and a client who was admitted during the night for 5 / 94 Correct Complete (ask patients to read back instructions) 16.What does TAPE stand for?: Teaching Assessment Planning Evaluation 17.What determines whether or not a nurse can delegate a task?: If the task requires TAPE, the nurse CANNOT delegate it (teaching, assessment, planning, evaluation) 18.As the RN, it is your responsible to tell the PCA what findings to look for, document, and report back to the nurse.: abnormal 19.PCAs are allowed to collect data on clients. This includes simple , not .: stable; observations; assessments 20.True or false. A PCA cannot replace a nasal cannula that has fallen out of a pt's nose.: False (PCAs are allowed to replace NCs if they fall out of the nose) 21.As a PCA, what type of I&Os charting are they not allowed to document?- : IVs 22.True or false. PCAs are NOT allowed to complete tasks that require profes- sional knowledge.: True 23.True or false. A PCA can make the decision to take off a pt's nasal cannu- la.: False 24.True or false. A PCA cannot redelegate tasks.: True 25.True or false. A PCA can administer a nebulizer treatment to a pt w/ pneumonia.: False 6 / 94 26.LPNs should only be assigned pts: stable 27.True or false. A patient with a CHRONIC condition can be stable.: True 28.LPNs are allowed to education, not education.: reinforce, teach 29.LPNs are allowed to do assessments, but not the assess- ments.: ongoing; initial 30.Who is in charge of completing the initial assessment on a pt?: The RN 31.Use the when prioritizing patience care: nursing process 32.What is the ONE exception to the ABC rule?: CPR --> instead of ABC, do CAB (compression, airway, breathing) 33. If an RN is in an emergency situation, an may be the priority (instead of an ).: intervention; assessment 34.When a question requires prioritization, answers may be correct, you just need to determine the order.: ALL; correct 35.Delegate the level of the task possible to the person.: - Highest; correct 36.1. You are the charge nurse making assignments for the next shift. Which patient would you assign to the LPN? a. 78 year old patient experiencing A-fib is on a Diltiazem gtt b. A 27 year old patient who is newly admitted with Diabetic Ketoacidos c. An 82-year old patient w/ Alzheimer's who has a colostomy and scheduled tube feedings 7 / 94 d. A 30-year old patient who is order to receive 2 units of PRBC's: c. An 82-year old patient w/ Alzheimer's who has a colostomy and scheduled tube feedings (it's okay because the LPN isn't setting up the INITIAL tube feeding) 37.1. On the unit, there is a new RN and an experienced RN, 2 LPNs and 2 PCAs. Which task delegated to one of the PCAs by the new RN needs to be reevaluated. SATA a. Apply Nystatin powder on skin after giving the patient a bath b. Assist the patient w/ administering a FLEETS ENEMA c. Emptying an Ostomy Bag d. Collecting and recording the pt's BP, HR, T, O2, R, and pain rating: a. Apply Nystatin powder on skin after giving the patient a bath b. Assist the patient w/ administering a FLEETS ENEMA 38.1. The nurse is caring for a severely ill patient w/ AIDS who now requires ventilator support. Which intervention is considered futile? a. Administering the influenza vaccine b. Providing oral care every 5 hours c. Applying fentanyl patches pm for pain d. Supporting the patient's lower extremities w/ pillows: a. Administering the influenza vaccine 39.1. What is the best example of the nurse practicing patient advocacy? a. Document all clinical changes in the medical record b. Notify the supervisor with conflicting procedural situations c. Understand the law as it apples to an error 10 / 94 - prioritized hand hygiene and cleanliness in the nursing profession to reduce infection rates - started nursing schools 45.By following the standard of care, nurses are able to ensure , , and nursing: knowledgeable, safe, and comprehensive 46.Licensure protects the FIRST.: public 47.Advocacy supports the .: patient 48.In advocacy, patients should be receiving the .: proper level of care 49.What is ethicacy?: the difficult decision between two different options 50.Primary focus of the healthcare system: ******: The fundamental purpose of health care is to enhance quality of life by enhancing health ******* 51.Only the health care team involved in the pt's care can access the pt's records: DIRECTLY 52.What does the continuity of care involve?: Effective coordination w/ the interpersonal team (within the hospital, from the hospital, and home care) 53.What kind of report do you give for continuity of care?: Verbal or written report 54.What is involved in the continuity of care report?: Patient hx Medications Physical and psychosocial needs Reason for admission Discharge plan Follow 11 / 94 up 55.What is the GOAL of discharge planning?: To decrease to length of stay (LOS) 56. What is the purpose of evidence-based practice (EBP)?: It serves as a *best* guide to make clinical decisions and to help us deliver the best help possible 57.Jenna is a nurse from the medical-surgical unit of a tertiary hospital. She was asked to float on the orthopedic in which she has no prior experience on working on. Which client should be assigned to her? a. A client with a cast for a fractured femur and who has numbness and discoloration of the toes. b. A client with balanced skeletal traction and needs assistance with morning care. c. A client who had an above-the-knee amputation yesterday and has currently has a temperature of 101.4ºF. d. A client who had a total hip replacement two days ago and needs blood glucose monitoring.: d. A client who had a total hip replacement two days ago and needs blood glucose monitoring. 58.The nurse plans care for a client in the post anesthesia care unit. The nurse should assess first the client's: a. Respiratory status. b. Level of consciousness. c. Level of pain. d. Reflexes and movement of extremities.: a. Respiratory status. 59.Nurse Charles of Nurseslabs Medical Center is planning care for a client who will undergo a colposcopy. Which of the following actions should Charles take first? a. Discuss the client's fear regarding potential cervical cancer. b. Assist with silver nitrate application to the cervix to control bleeding. 12 / 94 c. Give instructions regarding douching and sexual relations. d. Administer pain medications.: b. Assist with silver nitrate application to the cervix to control bleeding. 60.Nurse Mackenzie is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first? a. A client with diabetes being discharged today. b. A 35-year-old male with tracheostomy and copious secretions. c. A teenager scheduled for physical therapy this morning. d. A 78-year-old female client with pressure ulcer that needs dressing change.- : b. A 35-year-old male with tracheostomy and copious secretions. 61.A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the following assess- ment cues: pale. diaphoretic. blood pressure of 90/60. respirations of 33. The client is also anxious and fearing death. Which action should the nurse take first? a. Administer pain medications. b. Administer IV fluids. c. Administer dopamine. d. Administer oxygen via nasal cannula.: d. Administer oxygen via nasal cannula. 62.The charge nurse in the emergency department receives a call that four patients will be arriving immediately with various injuries. Based on the fol- lowing reports, order the patients from first to last to be seen. a. A pt with who hit his head w/ no obvious injuries. Pt is complaining of a headache and who is having trouble remembering his name. 15 / 94 70.Tasks RN's can delegate to LPN's: Monitoring findings (as input to the RN 's ongoing assessment) Reinforcing client teaching Tracheostomy care Suctioning Checking NG tube patency Administering enteral feedings Inserting a urinary catheter Administering medication (excluding IV meds) 71.5 rights of delegation (TCPDS - Tom's Cat Pees Down Stairs):: 1. Right task 2.Right circumstance 3.Right person 4.Right direction/communication 5.Right supervision/evaluation 72.Scope of practice for LPN: Vital signs, uncomplicated skills, stable clients, chronic diseases, Oral and IM, and medications. 73.Scope of practice for RN: ADPIE Clinical assessments Initial client education Discharge education Clinical judgment Initiating blood transfusion 74.Scope of practice PCA: Feeding (not at risk) Physical care - ADL's Ambulating Positioning 16 / 94 Specimen collection I/O totals Vital Signs on stable clients 75.Which of the following statements displays "right direction and communi- cation?" A. Delegate a PCA to assist Mr. Martin in room 312 with a shower before 0900. B. Delegate a PCA to assist Mr. Martin in room 312 with morning hygiene.: A. Delegate a PCA to assist Mr. Martin in room 312 with a shower before 0900. 76.Nurse delegating ambulation of client who had knee arthroplasty 5 days ago to an AP. Which of following info should nurse share with the AP? (Select all that apply.) A: The roommate is up independently B: Client ambulates with his slippers on over his antiembolic stockings C: Client uses front-wheeled walker when ambulating D: Client had pain med 30 min ago E: Client is allergic to codeine F: Client ate 50% of his breakfast this morning: B: Client ambulates with his slippers on over his antiembolic stockings C: Client uses front-wheeled walker when ambulating D: Client had pain med 30 min ago 77.Charge nurse is assigning client care for 4 clients. Which of the following tasks should the nurse assign to an LPN? A. Creating a plan of care for a client who is recovering following a stroke B. Assessing a pressure injury on a client who is on bed rest C. Providing NG suctioning for a client who has pneumonia 17 / 94 D.Teaching a client who has asthma to use a metered-dose inhaler: C. Provid- ing NG suctioning for a client who has pneumonia 78.A nurse is preparing an in-service program about delegation. Which of the following are components of the 5 rights of delegation? A. Right place B. Right supervision/evaluation C. Right direction and communication D. Right documentation E. Right circumstances: B. Right supervision/evaluation C. Right direction and communication E. Right circumstances 79.To be effective, discharge planning must begin during .: admis- sion 80. principles provide the rationale for nursing interventions.: Sci- entific 81.What is the Nursing Care Plan (NCP)?: the end product of the planning step (ADPIE) 82.Nurses organize the NCP (Nursing Care Plan) for 3 reasons:: Quick identifi- cation of: 1.Problems 2.Outcomes 3. Interventions to implement 83.What 2 things should be at the center of all therapeutic nursing interven- tions?: Caring + Professional behavior 20 / 94 89.Maslow's Hierarchy of Needs: (level 1) Physiological Needs (level 2) Safety and Security (level 3) Relationships, Love and Affection (level 4) Self Esteem (level 5) Self Actualization 90.4 examples of physiological needs (level 1):: ABCs Heart rate, rhythm, strength of contraction Nutrition Elimination 91.3 examples of safety and security (level 2):: Protection from injury Promote feeling of security Trust in nurse-client relationship 92.2 examples of love and belonging (level 3):: Maintain support systems Protect from isolation 93.4 examples of self esteem (level 4):: Control Competence Positive regard Acceptance/worthiness 94.3 examples of self actualization (level 5):: Hope Spiritual well being Enhanced growth 95.What 4 things does client education teach?: 1. How to maintain and promote health 2.How to prevent illness 3.How to restore health 21 / 94 4.How to adapt to permanent illness or injury 96.How to do know if a client understands what you are teaching them?: Use the "teach back" method 97.Elements of an effective teaching plan (5 steps):: Assessment Data/Analysis Planning Implementation Evaluation 98.What "grade level" is associated with patients in the hospital?: 6th grade 99.Client relevance:: the client's understanding of WHY they should be learning the info being provided to them 100. Client motivation:: the client's ability to ENGAGE in the learning process by deciding when, where, and how they will learn 101. What is cognitive learning?: includes all intellectual behaviors and requires thinking, the "thinking" domain 102. What type of learning takes place when a client learns the manifestations of hypoglycemia and can verbalize when to notify the provider?: cognitive learning 103. What are the 6 stages of the cognitive domain? (KCAASE): knowledge, comprehension, application, analysis, synthesis, evaluation 104. What are the 5 stages of the affective domain? (RRVOC): Receiving Responding Valuing Organization Characterization 105. What is affective learning?: a person's attitudes, values, and feelings, the "feeling" domain 22 / 94 106. What type of learning involves a client learning about the life changes necessary for managing Type 1 diabetes and then discussing their feelings about having diabetes?: Affective learning 107. What is psychomotor learning?: gaining skills that require mental and phys- ical activity, the "doing" domain 108. What are the 7 stages of the psychomotor domain?: Perception Set Guided Mechanism Complex Adaptation Origination 109. What type of learning involves clients practicing preparing their insulin injections?: Psychomotor learning 110. Teaching in groups often increases learning and learner satisfac- tion: smaller (6 people or fewer) 111. When providing client education, what grade level should you teach them at?: At the 6th- 8th grade reading level 112. 4 factors the enhance client learning:: 1. Perceived benefit 2.Cognitive and physical ability 3.Active participation 4.Age- and education level-appropriate methods 113. 5 barriers to client learning:: 1. Fear, anxiety, depression 2.Physical discomfort, pain, fatigue 3.Environmental distractions 25 / 94 120. 5 roles and responsibilities of the Nurse:: 1. Have a legal license to practice 2.ADPIE (perform assessments, establish diagnosis, goals, and interventions, conduct ongoing evaluations) 3.Develop inter-professional plans for client care 4.Share appropriate info to team members 5. Initiate referrals for client assistance (health education + community resources) 121. What is the nurse's code of ethics?: A guide for the expectations and standards of nursing care 122. What are ethical principles?: standards of what is right and wrong with regards to important social values and norms 123. Why are ethical principles important in caring for clients?: it guarantees respect for their autonomy and equitable treatment, and that they will receive the best care available based on their beliefs and decisions 124. Responsibility vs. Accountability: Responsibility: -willingness to respect obligation + following through on promises Accountability: -ability to answer for one's own actions 125. What is nonmaleficence?: do no harm 126. What is beneficence?: promoting good for others (with no self interest) 127. Why is the American Nurse's Association (ANA) important?: - a profes- sional organization for RNs - includes standards for nursing practice + professional performance - used when performing client care and instituting professionalism 26 / 94 128. Why is the National League of Nursing (NLN) important?: it promotes excellence in nursing education to build a strong and diverse nursing workforce to advance the health of our nation and the global community. 129. A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence: B. Autonomy 130. A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence: D. Beneficence 131. A nurse is instructing a group of nursing students about the responsibil- ities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifica- tions, the students should understand that this aspect of care delivery is an example of which ethical principle A. Fidelity 27 / 94 B. Autonomy C. Justice D. Nonmaleficence: C. Justice 132. A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence: D. Nonmaleficence 133. A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? A. A nurse on a med-surge unit demonstrates signs of chemical impairment B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints C. A family has conflicting feelings about the imitation of enteral tube feedings for their father, who is terminally ill D. A client who is terminally ill hesitates to name their partner on their durable power of attorney form: C. A family has conflicting feelings about the imitation of enteral tube feedings for their father, who is terminally ill 134. What is the State Nurse Practice Act?: law regulating practice of RN/LPN/APN within state, defines scope of practice within each state 30 / 94 2. standards of professional performance 142. Who is responsible for ensuring each nurse is practicing within legal laws of practice?: Each state's Board of Nursing (BON) 143. What organization must approve a new nursing program before it can open for enrollment?: BON (Board of Nursing) 144. 2 requirements to obtain a nursing license:: 1. Graduate from a nursing program approved by BON 2. Pass the NCLEX 145. What is the QSEN?: - Quality and Safety Education for Nurses - "competencies" developed to help prepare future nurses who will be needed in their health care environments to improve patient safety. 146. 7 civil laws in nursing:: 1. Negligence 2.Malpractice 3.Breach of confidentiality 4.Defamation of character 5.Assault 6.Battery 7.False imprisonment 147. What law protects health care workers from liability when they intervene at the scene of an emergency?: Good Samaritan law 148. What is professional negligence?: failure of a person who has professional training to act in a reasonable and prudent manner 31 / 94 149. What is informed consent?: - a legal process by which a client has given written permission for a procedure or treatment - consent is informed when the provider explains and the client understands all aspects of the treatment 150. What is the nurse's role in informed consent (6 things)?: 1. witness the client's signature on the informed consent form 2.ensure that informed consent has been appropriately obtained (provider gave all info and the client understood everything) 3.notify provider if the client has more questions or appears to not understand --> provider is responsible for clarification 4.document the client's questions, 5. reinforce provider's teachings 6.allow the client an interpreter for informed consent 151. What is an AMA?: against medical advice form, people sign it if they want to leave facility against doctors advice 152. What are advanced directives?: communicates a client's wishes concerning end-of-life care if the client is no longer able to make those decisions 153. What is the nurse's role in advanced directives (4 things)?: 1. Provide written information about advanced directives 2.Document the advanced directive status 3.Ensure advance directives reflect the client's current decisions 4.Inform all members of the health care team of the client's advance directive status 32 / 94 154. Types of advanced directives:: a) Living Will - expresses client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end of life issues b) Durable Power of Attorney for Health Care- designates a health care proxy who is an individual authorized to make health care decisions for a client who is unable c) Provider's Orders - Unless a DNR (do not resuscitate) or AND (allow natural death) order is written, nurse initiates CPR when client has no pulse or respiration. Written order for DNR or AND must be placed in client's medical record. 155. A nurse observes a PCA reprimanding a client for not using the urinal properly. The PCA tells the client that diapers will be used next time the urinal is used improperly. Which of the following civil laws (torts) is the PCA going against? A. Assault B. Battery C. False imprisonment D. Invasion of privacy: A. Assault -- it is a verbal threat 156. A nurse is caring for a competent adult client who tells the nurse "I am leaving the hospital this morning whether the doctor discharges me or not." The nurse believes that this is not in the client's best interest and prepares to administer a PRN sedative med that the client has not requested, along with the scheduled morning meds. Which of the following types of torts (civil laws) is the nurse going against? A. Assault 35 / 94 C. Commitment: A. Basic **the nurse thinks concretely, solely based on the rules** 164. A client is not ambulating as often because she doesn't want to miss her daughter's phone call. The nurse says the staff will listen and answer her phone for her. Which level of critical thinking by the nurse? A. Basic B. Complex C. Commitment: B. Complex **the nurse begins to express autonomy with her knowledge and experience** 165. A nurse increases the rate of an IV fluid infusion when a client's BP indicates hypovolemic shock 24 hours after surgery. A. Basic B. Complex C. Commitment: C. Commitment **nurse uses expert knowledge in decision-making) 36 / 94 166. 5 components of critical thinking (KENAS):: 1. knowledge base 2.experience 3.nursing process competencies 4.attitudes 5.standards 167. A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client, "Wi will call the surgeon and ask for a change in diet." The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? A. Basic B. Commitment C. Complex D. Integrity: A. Basic 168. A nurse receives a prescription for an antibiotic for a client who has cel- lulitis. The nurse checks the client's medical record, discovers that the client is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? A. Fairness B. Responsibility C. Risk-taking 37 / 94 D. Creativity: B. Responsibility 169. A newly licensed nurse is considering strategies to improve critical think- ing. Which of the following actions should the nurse take? SATA A. Find a mentor B. Use a journal to write about the outcomes of clinical judgements C. Review articles about evidence-based practices D. Limit consultations with other professionals involved in a client's care E. Make quick decisions when unsure about a client's needs.: A. Find a mentor B. Use a journal to write about the outcomes of clinical judgements C. Review articles about evidence-based practices 170. A nurse is caring for a client who has a new prescription for antihyperten- sive medication. Prior to administering the med, the nurse uses an electronic database to gather info about the medication and the effects it might have on the client. Which of the following components of critical thinking is the nurse using when he reviews the medication info? A. Knowledge B. Experience C. Intuition D. Competence: A. Knowledge 171. A nurse uses a head to toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence 40 / 94 **patients aren't required to have advance directives** 177. A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehab center. Which of the following tasks are the responsibility of the nurse at the transferring facility? SATA A. Ensure that the client has possession of their valuables B. Confirm that the rehab center has a room available at the time of transfer C. Assess how the client tolerates the transfer D. Give a verbal transfer report via telephone E. Complete a transfer form for the receiving facility: A. Ensure that the client has possession of their valuables B. Confirm that the rehab center has a room available at the time of transfer D. Give a verbal transfer report via telephone E. Complete a transfer form for the receiving facility **the nurse at the RECEIVING facility needs to assess the client upon arrival** 178. A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? SATA A. Advanced directives status B. Follow-up care C. Instructions for diet and medications D. Most recent vital sign data 41 / 94 E. Contact info for the home health care agency: B. Follow-up care C. Instructions for diet and medications E. Contact info for the home health care agency **advanced directive status and vital signs are essential for transfers, not discharge** 179. As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the clients family? A. Body mass index B. Usual times for meals and snacks C. Favorite foods D. Any difficulty swallowing: D. Any difficulty swallowing 180. *******: ***** 181. What is the nursing process?: A systematic problem-solving process that guides all nursing actions 182. What are the steps in the nursing process? ADPIE: Assessment Diagnosis Planning Implementation Evaluation 183. What is the purpose of assessment?: To establish a database about the patient's perceived needs, health problems, and responses to these problems 184. What 4 things do we do with the assessment?: Validate Interpret 42 / 94 Cluster data Documentation (must be thorough, concise, and accurate) 185. What is the purpose of diagnosis?: Identify patient problems FROM the data 186. What 3 things does the nurse do in the diagnosis step of the nursing process?: 1. Recognize patterns + trends 2.Compare data with expected standards/ranges 3.Arrive at conclusions to guide nursing care 187. is now referred to as a nursing problem: Diagnosis 188. What helps us prioritize care for our clients?: Maslow's Hierarchy of Needs 189. Most important patient needs (Maslow, levels 1-2):: Oxygen Fluid and electrolyte balance Perfusion Infection Change in mental status Safety 190. Next important patient needs (Maslow, level 3): Nutrition Elimination Mobility Skin integrity 191. Least important patient needs (Maslow, levels 4-5): Pain Coping Mental health 192. What is the purpose of planning?: set goals or care + desired outcomes identify appropriate nursing actions 45 / 94 E. Ask the patient to participate 200. What is the MAIN GOAL of the nursing process?: to organize and deliver nursing care 201. Documentation MUST be (3 things): Thorough Concise Accurate 202. How do nurses validate their assessments in ADPIE?: Lab and diagnostic tests 203. How to identify client problems from the data (3 things): ADPIE: 1. Recog- nize patterns + trends 2.Compare the data with expected standards or reference ranges 3.Arrive at conclusions to guide nrsing care 204. What does the "D" in ADPIE referred to as now?: the "nursing problem" based on the data 205. What is the difference between a nursing diagnosis and a medical diag- nosis?: Nursing diagnosis differs from medical diagnosis in that it includes "iden- tifying and discriminating between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen" only. RNs may not perform medical diagnosis. 206. Medical diagnosis vs. Nursing diagnosis: A medical diagnosis deals with disease or medical condition or pathology (treating or curing) A nursing diagnosis deals with the human response to bio-psycho-social stressors and/or major health problems that a nurse is licensed and competent to treat 207. Goals happen in which phase of the nursing process?: PLANNING 46 / 94 208. What is a nursing intervention?: any treatment based on clinical judgement and nursing knowledge that a nurse performs to achieve desired patient outcomes 209. 3 types of nursing interventions:: Independent Dependent Collaborative 210. What type of nursing intervention is within the RN's scope of practice and does NOT need an order?: Independent interventions 211. What type of nursing intervention MUST have an order?: Dependent inter- ventions 212. What type of nursing intervention is shared with other disciples?: Collab- orative interventions 213. What type of intervention is discharge planning?: Collaborative interven- tions (shared w/ OT, PT, and case manager) 214. Examples of independent nursing interventions:: turning and repositioning clients educating clients oral and skin care 215. Examples of dependent nursing interventions:: administering meds ambulating patients IV and foley insertions restraints hot and ice packs lab work 216. Situation: "Acute pain related to abdominal surgery as evidenced by pain level of 9/10 and abdominal guarding" 47 / 94 Ex of goal (concise and measurable): Ex of interventions:: Goal: Decrease pt's pain to 3-4/10 by end of shift Interventions: pain meds as ordered, nontherapeutic pain management, client edu- cation on abdominal recovery 217. What single question can quickly predict a client's literacy level + identify who is at risk for health literacy issues?: "How confident are you about filling out medical forms by yourself?" 218. What are psychomotor deficits?: When clients have difficulty performing fine and gross motor skills (reduced muscle strength, reduced motor coordination, reduced energy, decreased sensory and perception) 219. 5 elements of an effective client teaching plan:: Assessment Analysis Planning Implementation Evaluation 220. When clients learn effectively, they are able to their .: man- age; care 221. A nurse is providing teaching to a client who speaks a different language than the nurse. Which of the following actions should the nurse take? A. Ask the client's family member to translate B. Request a medical interpreter C. Ask another nurse on the unit to translate D. Provide the client with only written materials: B. Request a medical interpreter 222. A nurse is reviewing a client's plan of care. "The client will ambulate 20 feet using a walker" is the desired outcome. Which of the following aspects of the SMART goal should the nurse 50 / 94 the following information should the nurse include? SATA A. Improvement of health B. Provide knowledge about an illness or injury C. Relevance D. Health promotion E. Motivation: A. Improvement of health B. Provide knowledge about an illness or injury D. Health promotion 229. Nurses make up of the health professional workforce: 70% 230. A nurse is assessing a client's health literacy prior to providing care. Which of the following actions should the nurse take? SATA A. Ask questions regarding the client's health care needs and concerns B. Obtain a health history C. Assess the client's education level D. Perform a physical assessment E. Used medical terminology when educating the client: A. Ask questions re- garding the client's health care needs and concerns B. Obtain a health history C. Assess the client's education level 231. A nurse is reviewing information about client education with a newly licensed nurse. Which of the following information should the nurse include as the focus of client education? 51 / 94 A. Empowering clients to be accountable for self-care B. Providing the client with disease-oriented education C. Providing education only to the client to protect confidentiality E. Encouraging clients to let go of previous experiences: A. Empowering clients to be accountable for self-care 232. A nurse is teaching a client how to perform daily blood pressure readings at home. Which of the following statements by the client is an example of the teach-back method of learning? A. "Show me again how to position the blood pressure cuff on my arm" B. "I have an electronic blood pressure machine at home I can use" C. "I believe I can take my blood pressure successfully after talking through the steps" D. "Let me show you how I will take my blood pressure at home each day.": D. "Let me show you how I will take my blood pressure at home each day." 233. On a governmental level, the practice of nursing in the US is regulated by the:: Nurse Practice Act (NPA) 234. A nurse is teaching a group of nurses and asks which of the NLN in- tegrating competencies is defined as having respect for diversity, holistic care, client-centered approach, and client advocacy. Which of the following competencies does this describe? A. human flourishing B. nursing judgment C. patient-centered care D. spirit of inquiry: A. human flourishing 52 / 94 235. A nurse is providing education to a group of newly licensed nurses regarding the development of an identity as a nurse as well as the behavioral characteristics associated with nursing. Which of the following components of practice addresses the identity and characteristics of nursing? A. Standards to plan nursing care B. Standards of professional performance C. Standards of care D. Clinical practice guidelines: B. Standards of professional performance 236. A nurse holds a single state license and is preparing to move to another state. For the nurse to apply reciprocity, which of the following actions should 55 / 94 D.The level of care a nurse provides that is the same for all nurses who have comparable education, competency, and experience: D. The level of care a nurse provides that is the same for all nurses who have comparable education, competency, and experience 242. A nurse is educating a group of nurses about the Nurse Practice Act (NPA). Which of the following statements should the nurse include? SATA A. The NPA contains current laws and regulations for nursing practice B. The NPA is the same for all states C. The NPA contains standards and scope of practice D.The federal government enforces the NPA for each state E. The nurse is responsible to know current roles and responsibilities as defined by the NPA: A. The NPA contains current laws and regulations for nursing practice C. The NPA contains standards and scope of practice E. The nurse is responsible to know current roles and responsibilities as defined by the NPA 243. A nurse is providing client care using the nursing process. The nurse should identify that which of the following standards or guidelines includes this criterion? A. Standards of care B. Clinical practice guidelines C. Standards of practice D. Standard to plan nursing care: C. Standards of practice **includes explanatory statements* 244. A nurse is reviewing the licensing laws in their state of residence. Which of the following statements should the nurse use to define licensure? 56 / 94 A. "Licensure increases state revenue" B. "Licensure limits the number of practicing nurses" C. "Licensure protects the health and welfare of the public" D. "Licensure protects a nurse from a malpractice lawsuit": C. "Licensure pro- tects the health and welfare of the public" 57 / 94 245. Priority setting: the delivery of nursing care based on the urgency or impor- tance of client needs 246. 10 Priority Frameworks:: 1. Maslow's Hierarchy of Needs 2.ABCDE (Airway, Breathing, Circulation, Disability, Exposure) 3.The Nursing Process (ADPIE) 4.Safety and Risk Reduction 5.Least restrictive/Least invasive 6.Survive Potential 7.Acute vs. Chronic 8.Urgent vs. Nonurgent 9.Unstable vs. Stable 247. Which levels of Maslow's hierarchy are considered deficiency needs?: - The first 4 (security + safety, physiological, belonging + love, self esteem) 248. Which level of Maslow's hierarchy is considered a growth need?: Self-ac- tualization 249. According to Maslow's theory, needs must be met before fulfill- ing needs, and needs must be met before self-actualization needs can be fulfilled.: physiological; psychological; psychological 250. 6 ways to evaluate circulation:: 1. BP 2.Capillary refill time 3.Pulse rate, volume, character 60 / 94 C. Skin integrity D. Blood pressure: D. Blood pressure **one way to measure circulation is checking BP) 261. A nurse is caring for a client who is experiencing unexpected manifes- tations with several body systems. Which of the following priority setting frameworks should the nurse use to prioritize client assessment? A. Acute vs. chronic B. ABCDE 61 / 94 C. Least restrictive/least invasive D. Survive potential: B. ABCDE 262. What does SOAP mean?: S: subjective - client states.... O: objective - physical assessment A: assessment - diagnosis/problem P: plan 263. Direct vs Indirect nursing care:: Direct - requires client contact (wound dressings) Indirect - charting, documenting, etc. 264. A nurse is speaking with a client who is noncompliant in performing a daily blood glucose testing regimen. Which of the following responses should the nurse make? A. "It's important that you monitor your blood glucose, or you can have more health problems." B. "What is preventing your consistency with your daily blood glucose?" C. "Explain why you are not doing your daily blood glucose checks." D. "Do you understand the purpose of the daily checks?": B. "What is preventing your consistency with your daily blood glucose?" **open ended questions encourage clients to talk more** 265. A nurse is caring for a client who is being transferred to another unit, but the receiving nurse is unavailable to take report. Which of the following concepts is being violated that could place the client at risk? A. Quality assessment checks B. Interprofessional collaboration C. Continuity of care 62 / 94 D. Consistent client monitoring: C. Continuity of care 266. Who established the Code of Ethics for nurses?: ANA (American Nurses Association) 267. 6 ethical principles that have a direct effect on nursing care:: 1. Autonomy 2.Beneficence 3.Nonmaleficence 4.Veracity 5.Fidelity 6. Justice 268. 5 professional values of nursing (AAHIS):: 1. Altruism 2.Autonomy 3.Human Dignity 4. Integrity 5.Social Justice 269. Main differences between criminal law vs. civil law: - With criminal law, a prosecutor has the burden of proof to show a nurse has violated a criminal standard "beyond a reasonable doubt." - Criminal law can be used by the public to punish defendants and deter future crime - Civil law deals with disputes between individuals or between an individual and an organization. 270. What does "tort" mean in legal practice?: carrying out an act (or failing to act) against 65 / 94 277. The family of a pt angrily states the pt's code status is wrong and should be changed. What is the action of the nurse A. Respect the wish of the pt B. Ignore the family member C. Call the Ethics committee D. Apologize and change it: A. Respect the wish of the pt 278. The patients privacy is protected by: A. Continuity of care B. Hospital passwords C. HIPPA D. Nurse practice act: C. HIPPA 279. A SN forgets that a pt is NPO, asks a PCA to bring in water, Luckily a nurse stops her, The SN states, it was my fault A. Ex of advocacy B. Ex of accountability C. Ex of honor D. Ex of justice: B. Ex of accountability 280. A RN on a Med Surg floor falls behind schedule administering meds. Which of the other RN tasks can be delegated to a UAP A. The assessment of a pt who has just arrived on the floor 66 / 94 B. Teaching a pt w/ newly diagnosed diabetes about foot care C. Helping a pt who recently had surgery OOB for the first time D. Documentation of a pt's IOs in the chart: D. Documentation of a pt's IOs in the chart 281. A RN delegates a procedure to a LPN. This act of delegation is used primarily to: A. Improve productivity B. Create change C. Establish a network D.Transfer accountability: A. Improve productivity 282. What assignment would be most appropriate for a RN? A. Applying a condom cath on a client who is incontinent B. Taking a pulse of a client w/ dysrhythmia C. Changes the linen on an occupied bed on a client who is comatose D.Transferring a client from a bed to chair w/ a mechanical lift: B. Taking a pulse of a client w/ dysrhythmia 283. There are Five Rights of Delegation, right task, right person, right com- munication, right time and right? A. Feedback/Evaluation B. Preceptor C. Route D. Place: A. Feedback/Evaluation 67 / 94 284. Which of the staff members does the nurse assign to provide morning care for an older patient who needs help w/ADL's? A. LPN B. PCA C. Restorative aid D. Cardiac monitor tech: B. PCA 285. RN and NA are working w/ patients who need coughing, deep breathing, IS, and leg exercises. The nurse directs the NA to A. Document in the medical record when exercises are complete B. Teach and demonstrate leg exercises C. Observe the pt doing IS for the first time D.To inform the RN that the pt is unwilling to perform leg exercises: D. To inform the RN that the pt is unwilling to perform leg exercises 286. When working within a nursing team, which intervention should a RN perform rather than a UAP A. Measuring IOs B. Providing a bed bath C. Assessing skin of a newly admitted client D. Offering apple juice to a client on a clear liquid diet: C. Assessing skin of a newly admitted client 287. A discharge task you can delegate to a nursing assistant is: 70 / 94 By supporting the pt you are A. Showing justice B. Being non maleficence C. Being an advocate D. Showing fidelity: C. Being an advocate 295. A pt going for a simple surgery know she will be going home the same day. The patient will check in as a A. pt through the ED B. OR transfer C. Outpatient D. Inpatient: C. Outpatient 296. Which one will the nurse see first: A. Pt on contact precautions B. Pt who has complained about his room C. Pt whose daughter has arrived D. Pt with WBC of 0.5: D. Pt with WBC of 0.5 297. After a foley is removed. How many hours does your patient have to void? A. 6-8 B. 3-6 C. 1-3 71 / 94 D. Right away: A. 6-8 298. In Prioritizing patients, we use the ABC rule unless its an emergency, THE A stands for A. apply B. ambulation C. airway D. access: C. airway 299. A medication can be given 30 min before or 30 min after its due A. True B. False: True 300. A nurse is describing the patient's characteristics as confusion and tired the SN understands these are S/S of A. Hyperglycemia B. being bored C. non compliance D. Hypoglycemia: D. Hypoglycemia 301. Policies that nurses use are based on and serve as a guide A. hospital policy B. NCLEX C. Evidenced Based Practices 72 / 94 D. Board of Nursing: C. Evidenced Based Practices 302. A SN forgets to lock a patient's chair, upon sitting down the chair slides back and the patient falls, this is an ex of A. Responsibility B. Negligence C. Malpractice D. Abuse: B. Negligence 303. In caring for a client with pain and discomfort, which task is most appro- priate to delegate to the nursing assistant? A. evaluate relief after applying a cold application B. monitor the pt for signs of discomfort while ambulating C. assist the client w/ preparation of a sitz bath D. coach the client to take deep breaths during a painful procedure: C. assist the client w/ preparation of a sitz bath 304. The MD ordered a placebo for a chronic pain client. You are newly hired, you feel very uncomfortable admin, you should A. Check the policy regarding the use of placebo B. contact the charge nurse C. prepare the medication and hand it to the MD D. follow a personal code of ethics and refuse: B. contact the charge nurse 305. A major rationale for the development and continuation of professional nursing 75 / 94 312. A VNA nurse is visiting a pt to teach about a new colostomy. The pt says I don't want to deal w/ this. The pt is showing A. signs of fear B. signs of aggression C. a lack of motivation D. ignorance: C. a lack of motivation 313. A nurse is teaching a pt on d/c how to admin insulin inj. The pt gets frustrated, and repeats questions. The nurse will A. slow down and continue teaching B. ask the pt what is the problem C. come back in an hour and reinforce teaching D. tell the pt to practice at home: C. come back in an hour and reinforce teaching 314. A nursing student is reading over laws that govern nursing practices in each state. Who or what would be providing this material? A) American Nursing Association B) Nursing Practice Act C) National League of Nursing D) Good Samaritan Law: B) Nursing Practice Act The NPA is the law for governing nursing practice in each state and is used for guidance to action. Therefore, the NPA has terms and phrases clearly defined for the state boards of nursing to use for enforcement. 315. A nurse is caring for a client. What following task can an RN delegate to an LPN? 76 / 94 A) Document a new assessment for a newly admitted client B) Teach a newly admitted client how to use an incentive spirometer C) Assess and document a client's apical pulse D) Provide colostomy care on an established colostomy: D) Provide colostomy care on an established colostomy 316. In what part of the nursing process would a nurse determine if interven- tions were successful and goals were completed? A) Assessment B) Planning C) Implementation D) Evaluation: D) Evaluation 317. A nurse witnesses another nurse give an injection to a client who is unwilling to receive the injection. What did the nurse just witness? A) Assault B) Battery C) False Imprisonment D) Defamation: B) Battery 318. A nurse is assessing a newly admitted client. What would qualify as "subjective" in the assessment by the nurse? Select all that apply: A) Patient states pain in right leg B) Patient c/o sore throat 77 / 94 C) Patient has visible rash on right arm D) Patient smells like they haven't bathed in a week E) Patient states their shower is broken: A) Patient states pain in right leg B) Patient c/o sore throat E) Patient states their shower is broken 319. True or False: A nurse should discuss with the patient what they believe the client's medical diagnosis is.: False - the nurse cannot diagnose a patient with a medical diagnosis 320. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? A) A client c/o of 4/10 pain who is scheduled to go for an X Ray B) A client requires a dressing change C) A client with a BP of 148/101 D) A client receiving nasal O2 who had trouble breathing last shift: D) A client receiving nasal O2 who had trouble breathing last shift Know your ABC! 321. A nurse is very busy and needs assistance. What task can the nurse delegate to an UAP: A) Ambulate post-op patient for the first time B) Assessing the sound and rhythm of a client's pulse C) Checking to see if a client's rash has gotten worse D) Provide basic ostomy care on an established ostomy bag: D) Provide basic ostomy care on an 80 / 94 C) Informed Consent D) Autonomy Document: B) Durable Power of Attorney 328. What situation would fall under "unintentional" tort law in the form of negligence? A) a patient deemed as a fall risk, falls due to not turning a bed alarm on B) a nurse administers the wrong medication and causes harm C) a nurse threatens a patient with an injection if they refuse to calm down D) a nurse restrains a patient to the bed: A) a patient falls due to not turning a bed alarm on 329. A prisoner is rushed to the ER with a laceration wound. After stabilizing the patient, the corrections officer asks the nurse what the client's HIV status is. What is an appropriate response from the nurse: A) provide the CO with the information B) tell the CO they must ask the patient C) give the CO a health information proxy sign off form D) provide the information to the warden, who can then give the information to the CO: B) tell the CO they must ask the patient 330. What is the 4th C of delegation? Correct, Clean, Complete... A) Client B) Concise C) Care D) Comfortable: B) Concise 81 / 94 331. True or False: An RN can delegate follow up incentive spirometer educa- tion to an established client: True 332. A nurse is providing education to a client who has been newly diagnosed with diabetes. The nurse shows the client how to inject themselves with insulin. What domain of learning would this relate to? A) Cognitive B) Affective C) Psychomotor D) Motivation: C) Psychomotor 333. True or False: Responsibility is taking ownership over a result or outcome of your actions: False - accountability is taking ownership over a result or outcome of your actions 334. A nurse receives their start of shift report. Who should the nurse see first? A) 22 yr old admitted with viral gastroenteritis c/o N/V/D B) 42 year old 24 hours post thyroidectomy who is complaining of headache and pain at the incision site C) 50 year old admitted 72 hours ago for ckd with uop of 220mL in 8 hours and hands and feet are edematous D) A 64 year old admitted yesterday for hypertension, hf, digitalis toxicity with frequent PVCs (premature ventricular complexes): D) A 64 year old admitted yesterday for hypertension, hf, digitalis toxicity with frequent PVCs (premature ventricular complexes) indicated potassium imbalance; hypokalemia, dysrhythmias can rapidly deteriorate to ventricular tachycardia or sudden death. 82 / 94 A - potential electrolyte imbalance is not the priority B and C - are expected per situation 335. True or False: The following goal is measurable: A client will ambulate today: False 336. You are taking care of 4 clients. At the start of your shift, what client should you see first? A) An 82 year old client with COPD who has a current 88% O2 level B) A 75 year old client who is post operation for hip arthroplasty with a temperature of 101.2 F C) A 22 year old client admitted for nausea and vomiting with a BP of 153/90 D) A 36 year old post op complaining of 8/10 pain: C) A 22 year old client admitted for nausea and vomiting with a BP of 148/90 Situational ABC Answer is not A because, although low, would be a normal baseline for somebody with COPD 337. True or false: A nursing diagnosis assists in identifying the disease and condition of the client: False - nursing diagnosis is a clinical judgement to potential health / life problems. 338. A patient is currently receiving dialysis treatment. What level of care would this be considered? A) Primary B) Restorative C) Secondary D) Tertiary: D) Tertiary 85 / 94 C) Planning D) Implementation E) Evaluation: C) Planning 348. A client is set to receive 1000 mL of saline over 8 hours. How many mL per hour will the nurse set the infusion pump?: 125 mL/hr 349. You are caring for a patient with esophageal cancer. Which task could be delegated to a UAP? A) Assisting the patient with oral hygiene B) Observing the patient's response to feedings C) Facilitating expression of grief or anxiety D) Initial weighing: A) Assisting the patient with oral hygiene 350. The nursing care plan for the client with dehydration includes interven- tions for oral health. Which interventions are within the scope of practice for 86 / 94 an LPN being supervised by a nurse? (Select all that apply.) A) Reminding the client to avoid commercial mouthwashes B) Encouraging mouth rinsing with warm saline C) Observing the lips, tongue, and mucous membranes D) Providing mouth care every 2 hours while the client is awake E) Seeking a dietary consult to increase fluids on meal trays: A, B, C, D 351. An experienced LPN, under the supervision of the RN, is providing nurs- ing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/ LVN? SATA A) Auscultating breath sounds B) Administering medications via metered-dose inhaler (MDI) C) Completing in-depth admission assessment D) Checking oxygen saturation using pulse oximetry E) Developing the nursing care plan F) Evaluating the patient's technique for using Metered dose inhaler: A) Aus- cultating breath sounds B) Administering medications via metered-dose inhaler (MDI) D) Checking oxygen saturation using pulse oximetry 352. After a client has a seizure, which action can you delegate to the UAP? A) Documenting the seizure B) Performing neurologic checks 87 / 94 C) Taking the client's vital signs D) Restraining the client for protection: C) Taking the client's vital signs 353. The plan of care for a diabetic patient includes all of these interventions. Which intervention should you delegate to a UAP? A) Checking to make sure that the patient's bath water is not too hot B) Discussing community resources for diabetic outpatient care C) Teaching the patient to perform daily foot inspection D) Assessing the patient's technique for drawing insulin into a syringe: A) Checking to make sure that the patient's bath water is not too hot 354. As the shift begins, you are assigned to care for the following patients. Which patient should you assess first? A) 38-year-old w Graves disease and a heart rate of 94 beats/ min B) 63-year-old w type 2 diabetes and fingerstick glucose level of 137 mg/ dL C) 58-year-old w hypothyroidism and a heart rate of 48 beats/ min D) 49-year-old w Cushing disease and dependent edema rated as 1 +: C) 58-year-old w hypothyroidism and a heart rate of 48 beats/ min 355. Which client should you assess first? A) Client w/ deep partial-thickness burns on both legs c/o severe and contin- uous leg pain B) Client who has just arrived from the ED w/ facial, mouth and neck burns sustained in a house fire 90 / 94 359. True of False. The nurses code of ethics is a moral statement of account- ability?: True 360. True or false. Upon transfer of a client to another hospital unit, the outgoing RN should give report to the receiving RN ASAP.: True 361. True or False. The RN can delegate to the UAP to ambulate a stable 3 day post op client in the hall?: True 362. True or false. The RN can delegate to the LPN ostomy care to a client with an established ostomy?: True 363. True or false. The RN can delegate the assessment of a newly admitted client to the LPN?: False 364. True or false. The RN can delegate trach care to the LPN for a client with a newly placed tracheostomy?: False 365. A RN delegates a procedure to a LPN, this act of delegation is used primarily to: A. create change B. transfer accountability C. improve productivity D. establish a network: C. improve productivity 366. Which of these is a measurable goal? A. The client will get OOB 3x a day B. The client will be pain free C. The client will ambulate D.The client will urinate: A. The client will get OOB 3x a day 91 / 94 367. Which of these problems is the highest priority? A. Infection B. Pain C. Pressure ulcer D. SOB: D. SOB 368. In which step of the nursing process are goals set? A. Assessment B. Implementation C. Planning D. Data/Analysis: C. Planning 369. True or false. Florence Nightingale recognized that systematic education in both theory and practice was essential to prepare nurses: True 370. Which client should be assessed first? A. Client c/o pain in legs B. Client w/ temp of 100.3 F C. Client w/ pulse ox of 88% D. Client w/ BP of 142/82: C. Client w/ pulse ox of 88% 371. True or false. You can use a medical diagnosis in your nursing diagnostic statement.: False 372. True or false. If a nurse cannot care for a client objectively, they can choose to 92 / 94 decline to care for that client.: True 373. A breach of duty by failure to meet standards and has caused harm is.... A. Intentional tort B. Negligence C. HIPPA D. Mandatory reporting: B. Negligence 374. Which statement describes the purpose of the ANA standards of nursing practice? A. Policy statements defining the obligations of nurses B. Legal statutes that guide nursing actions C. Progressive actions for a nursing procedure D. Requirements for RN licensure: A. Policy statements defining the obligations of nurses 375. A nurse observes another nurse treating a client in an abusive manner. What should the nurse do first? A. Talk w/ the nurse about the incident B. Tell the nurse in charge and write a report C. Become a role model for the other nurse D. Reassure and calm the client: D. Reassure and calm the client 376. A health history is obtained in which step of the nursing process? A. Assessment B. Evaluation