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A nurse and AP are planning to receive a patient who sustained a traumatic head injury in a motor vehicle accident. Which activity can the nurse safely delegate to the AP?
- A. Collecting information for a health history
- B. Performing a physical assessment
- C. Contacting the health care provider for medical orders
- D. Preparing the bed and collecting needed supplies
Correct Answer: D
Rationale: The nurse may delegate preparation of the bed and collection of needed supplies to assistive personnel but performs the other activities listed, as they require clinical judgment and specialized skills.
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A home care nurse is observing the patient's family member perform a wound irrigation and dressing change for a postoperative wound dehiscence containing purulent drainage. In which situation will the nurse provide additional education?
- A. The family member places the old dressing in a separate bag at the bedside.
- B. The patient takes an analgesic a half-hour prior to the dressing change.
- C. The family member states they washed their hands an hour ago.
- D. The patient returns to bed during the dressing change.
Correct Answer: C
Rationale: The nurse teaches the patient and family to effectively wash their hands before and after having direct contact with the patient, before performing invasive procedures, when handling dressing or touching open wounds, and when administering medications or feeding the patient. All other options are correct.
A visiting nurse is performing the initial assessment and plan for a patient who receives Medicare and was recently discharged from the acute care hospital. Before implementing the plan of care, what follow-up is required by the nurse?
- A. Validating the patient's consent for care
- B. Obtaining the health care provider's signature and approval
- C. Determining how the patient will pay for services
- D. Ensuring that a family member or friend can assist with implementation
Correct Answer: B
Rationale: The nurse assesses the patient eligible for home services and presents the plan to the health care provider for approval. This approval the plan allows for provision of care and reimbursement of services.
A discharge nurse manager is preparing the plan for a patient returning home after receiving a kidney transplant. What actions will the nurse perform to ensure continuity of care? Select all that apply.
- A. Conduct an admission health assessment
- B. Evaluate the effectiveness of the current nursing care plan
- C. Participate in transferring the patient to the postoperative care unit
- D. Make referrals to appropriate facilities
- E. Maintain records of patient satisfaction with services received
- F. Assess the strengths and limitations of the patient and family
Correct Answer: B,D,F
Rationale: The primary roles of the discharge planner as patients move from acute to home care are evaluating the nursing plan for effectiveness of care, making referrals for patients, and assessing the strengths of patients and their families. The staff typically performs an admission health assessment and assists with patient transfers from the OR. In most facilities, maintaining records of patient satisfaction is the role of the public relations manager or office manager.
A nurse is considering moving from the hospital setting to home health care. In speaking with other professionals, what qualities does the nurse find they should possess to be successful? Select all that apply.
- A. Making accurate assessments
- B. Researching new treatments for chronic diseases
- C. Communicating effectively
- D. Delegating tasks appropriately
- E. Performing clinical skills effectively
- F. Making independent decisions
Correct Answer: A,C,E,F
Rationale: Nurses working in the community must have the knowledge and skills to make accurate assessments, work independently, communicate effectively, and perform clinical skills accurately. Community-based nurses may be researchers and occasionally delegate care, but these are not key qualities for this type of nursing.
A nurse is caring for a patient who has been hospitalized for dehydration secondary to a urinary tract infection. The patient states, 'I'm leaving. There are too many germs here, and I'll probably get sicker than when I came in.' As this patient has capacity for decision making, which response is most consistent with the nurse's legal accountability?
- A. Only the primary health care provider can authorize your discharge from a hospital.
- B. Let me gather your belongings and prepare the discharge paperwork.
- C. I will inform the health care provider that you want to leave and request a psychiatric consult.
- D. Your choice carries risks for complications, so I must ask you to sign a release form.
Correct Answer: D
Rationale: The patient is legally free to leave the hospital against medical advice (AMA); however, patients who who leave AMA must sign a form releasing the health care provider and hospital from legal responsibility for their health status. This signed form becomes part of the medical record.