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A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?
- A. A client who has Guillain-Barre syndrome
- B. A client who has a lumbosacral spinal tumor
- C. A client who has systemic sclerosis
- D. A client who has amyotrophic lateral sclerosis (ALS)
Correct Answer: B
Rationale: The correct answer is B. A client with a lumbosacral spinal tumor may need assistance with meals due to potential mobility limitations or weakness. The nurse can delegate this task to the AP as it falls within their scope of practice. Clients with Guillain-Barre syndrome (choice A) may have muscle weakness and difficulty swallowing, requiring skilled nursing assessment during mealtime. Clients with systemic sclerosis (choice C) may have gastrointestinal involvement, necessitating careful monitoring during meals. Clients with ALS (choice D) have progressive muscle weakness, making it crucial for a nurse to assess their ability to eat safely. Delegating meal assistance for these clients to an AP may compromise their safety.
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A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Which of the following tasks should the charge nurse reassign to a licensed nurse?
- A. Providing a back rub to a client who has right-sided paralysis
- B. Transporting a client who experienced a stroke 72 hr ago to the radiology department
- C. Performing oral hygiene for a client who is 1 day postoperative following an amputation of the right arm
- D. Removing and cleaning the cannula of a client who has a new tracheostomy
Correct Answer: D
Rationale: The correct answer is D because removing and cleaning the cannula of a client with a new tracheostomy requires specialized skills and knowledge that only a licensed nurse possesses to prevent complications and ensure safety. Providing a back rub (A) can be delegated to an AP as it is within their scope of practice. Transporting a stroke client (B) and performing oral hygiene post-amputation (C) can also be delegated as they do not involve complex nursing assessments or interventions. It is crucial to reassign the tracheostomy care task to a licensed nurse to maintain the client's airway safely.
A charge nurse is planning care for a unit with limited staffing due to a flu outbreak. Which of the following actions should the charge nurse prioritize?
- A. Assign assistive personnel to provide client education on hand hygiene.
- B. Ensure all clients receive their scheduled baths on time.
- C. Reassess clients with unstable vital signs every 2 hours.
- D. Delegate documentation of intake and output to the unit clerk.
Correct Answer: C
Rationale: The correct answer is C: Reassess clients with unstable vital signs every 2 hours. This is the priority because clients with unstable vital signs require frequent monitoring to detect any deterioration or changes in their condition promptly. This action directly impacts patient safety and allows for timely intervention if needed.
Assigning assistive personnel for client education (A) is important for infection control but may not be the priority during a staffing shortage. Ensuring scheduled baths (B) is important for hygiene but can be delayed if necessary. Delegating documentation of intake and output (D) to the unit clerk is not appropriate as it involves clinical judgment and assessment.
A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation?
- A. Delegation provides appropriate resources for the client.
- B. Delegation promotes discharge teaching activities for clients.
- C. Delegation permits a designated individual to meet a goal on your behalf.
- D. Delegation decreases health care costs.
Correct Answer: C
Rationale: Rationale: Answer C is correct because delegation allows a designated individual to accomplish a specific task or goal on behalf of the delegator. This ensures efficient and effective delivery of care while maximizing resources. Option A is incorrect as it refers to resource allocation, not delegation's purpose. Option B is incorrect as delegation is not solely for discharge teaching. Option D is incorrect as while delegation may contribute to cost-effectiveness, it is not its primary purpose.
A nurse is obtaining informed consent from a client who is preoperative. Which of the following actions should the nurse take? (Select all that apply.)
- A. Verify the client understands the surgical procedure.
- B. Validate the signature is authentic.
- C. Confirm that the consent is voluntary.
- D. Explain the surgical procedure to the client.
- E. Establish that the client is able to pay for the surgical procedure.
Correct Answer: A,B,C
Rationale: Correct Answer: A, B, C
Rationale:
A: Verifying the client understands the surgical procedure ensures they are informed about what will occur during surgery.
B: Validating the signature is authentic confirms the client has personally given consent, enhancing legal protection.
C: Confirming consent is voluntary ensures the client is not coerced or pressured, upholding ethical principles.
Summary:
D: Explaining the surgical procedure is important but not solely the nurse's responsibility for obtaining consent.
E: Ability to pay is not a factor in obtaining informed consent.
Overall, A, B, and C are crucial steps to ensure informed and voluntary consent.
A nurse manager is preparing an inservice program about managing conflict for the nurses on the unit. The nurse manager should identify which of the following examples as interpersonal conflict?
- A. An experienced nurse is uncivil to a newly licensed nurse
- B. A nurse is uncertain about joining a professional nursing organization
- C. Nurses on the unit disagree about what time of day daily client weights should be obtained
- D. A nurse who just lost his spouse does not want to be assigned to care for a terminally ill client
Correct Answer: A
Rationale: The correct answer is A because it involves a direct conflict between two individuals, the experienced nurse and the newly licensed nurse. This type of conflict is interpersonal in nature as it pertains to personal interactions and relationships. The experienced nurse's uncivil behavior towards the newly licensed nurse indicates a clash of personalities or communication styles.
Choice B is incorrect as it does not involve a conflict between individuals but rather an internal struggle of the nurse deciding whether to join a professional organization. Choice C is incorrect as it describes a disagreement among nurses about a work-related task, which is more of an intragroup conflict. Choice D is incorrect as it represents a personal issue of the nurse dealing with grief, not a conflict with another individual.