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A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation?
- A. Assigning the most competent RN to perform a central line dressing change
- B. Assigning the most efficient AP to perform glucometer monitoring for each client
- C. Assigning two assistive personnel (AP) to ambulate all clients
- D. Assigning a new graduate nurse to perform a wet-to-dry dressing change
Correct Answer: D
Rationale: Correct Answer: D - Assigning a new graduate nurse to perform a wet-to-dry dressing change.
Rationale:
1. Wet-to-dry dressing changes require advanced skill and knowledge.
2. New graduate nurses may not have sufficient experience to perform this task safely.
3. Risk of complications such as infection or tissue damage is higher with inexperienced staff.
Summary of Other Choices:
A: Assigning the most competent RN to perform a central line dressing change - Competent RNs are appropriate for this task.
B: Assigning the most efficient AP to perform glucometer monitoring - Routine task suitable for AP.
C: Assigning two AP to ambulate all clients - Ensures safety and efficiency in patient care.
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A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of both of the nurses' clients while they are at lunch. The charge nurse is demonstrating which of the following types of conflict management?
- A. Cooperating
- B. Compromising
- C. Avoiding
- D. Competing
Correct Answer: A
Rationale: The correct answer is A: Cooperating. The charge nurse is demonstrating cooperation by taking on the responsibility of caring for both nurses' clients while they go to lunch together. This approach shows a willingness to collaborate and find a solution that benefits all parties involved. By cooperating, the charge nurse is promoting teamwork and fostering a positive work environment.
Summary of other choices:
B: Compromising - This would involve finding a middle ground or making concessions, which is not the case in this scenario.
C: Avoiding - This would involve ignoring the conflict or avoiding confrontation, which is not what the charge nurse is doing.
D: Competing - This would involve a win-lose mindset where one party wins at the expense of the other, which is not evident in this situation.
A charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries requires follow-up?
- A. Client received 2 mg morphine IV at 0900 for pain rated 6/10.
- B. Client's blood pressure is normal after medication administration.
- C. Client refused morning medications; provider notified.
- D. Client's wound dressing changed at 1100 per protocol.
Correct Answer: B
Rationale: Describing blood pressure as 'normal' is vague and lacks specific data, requiring follow-up to ensure accurate and complete documentation.
A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply.)
- A. Ambulate an older adult client who has hypertension.
- B. Provide discharge instructions for a client who has a new skin graft.
- C. Check a blood product with another nurse prior to administration.
- D. Weigh a client who has heart failure.
- E. Perform an admission assessment on a client.
Correct Answer: A,D
Rationale: The correct tasks to assign to an assistive personnel (AP) are A and D. APs are trained to assist with basic care activities. Ambulating an older adult client with hypertension and weighing a client with heart failure are within the scope of practice for APs as they do not involve complex assessments or critical decision-making. Providing discharge instructions (B) requires specialized knowledge and education, which is beyond the scope of an AP. Checking a blood product (C) and performing an admission assessment (E) require specific training and expertise that only licensed nurses should perform.
A nurse is teaching a group of newly hired nurses about the requirements for disaster planning. Which of the following statements by one of the newly hired nurses indicates an understanding of the teaching?
- A. A staff nurse can function as the incident commander.
- B. An actual disaster cannot take the place of a disaster drill.
- C. A physician must triage victims of a disaster in the emergency department.
- D. Disaster drills should be held on a regular basis.
Correct Answer: D
Rationale: The correct answer is D: Disaster drills should be held on a regular basis. This is essential for preparedness and practice in handling emergencies. Regular drills help ensure staff are familiar with procedures, can identify areas for improvement, and maintain readiness.
Incorrect choices: A: A staff nurse typically does not serve as the incident commander, who is usually a designated leader with specific training. B: While disaster drills are crucial, an actual disaster is unpredictable and serves a different purpose. C: Triage in a disaster is often done by trained personnel such as nurses or paramedics, not just physicians.
A nurse in a provider's office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?
- A. WBC 6,000/mm3
- B. BUN 15 mg/dL
- C. Hemoglobin 14 g/dL
- D. Platelet count 60,000/mm3
Correct Answer: D
Rationale: The correct answer is D: Platelet count 60,000/mm3. A low platelet count (thrombocytopenia) can increase the risk of bleeding during surgery. Normal platelet count is around 150,000-450,000/mm3. The other options are within normal ranges: A) WBC 6,000/mm3 is normal, B) BUN 15 mg/dL is normal, and C) Hemoglobin 14 g/dL is normal. Therefore, the nurse should follow up on the platelet count to ensure the client's safety during surgery.