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A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation?
- A. "Right client"
- B. Right supervision/evaluation
- C. Right direction/communication
- D. Right time
- E. Right circumstances
Correct Answer: B, C, E
Rationale: The correct answer is B, C, and E. The 5 rights of delegation are essential for safe and effective delegation. Right supervision/evaluation ensures appropriate oversight, feedback, and accountability. Right direction/communication emphasizes clear instructions and open communication. Right circumstances consider factors like workload and resources. Right client (choice A) and right time (choice D) are not part of the 5 rights of delegation. In summary, choices A and D are incorrect because they do not align with the established principles of delegation, while choices B, C, and E are crucial components for successful delegation.
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A nurse educator is teaching a module on safe med administration to newly hired nurses. Which of the following statements by the newly hired nurse indicate understanding of the nurse's responsibility when implementing med therapy? Select all.
- A. I will observe for med side effects.
- B. I will monitor for therapeutic effects.
- C. I will prescribe the appropriate dose.
- D. I will change the dose if adverse effects occur.
- E. I will refuse to give a med if I believe it is unsafe.
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. A nurse's responsibility in implementing medication therapy includes observing for side effects (A), monitoring for therapeutic effects (B), and refusing to give a medication if they believe it is unsafe (E).
A - Observing for side effects is crucial in ensuring patient safety and prompt intervention if adverse reactions occur.
B - Monitoring for therapeutic effects helps assess the effectiveness of the medication in achieving the desired outcomes for the patient's condition.
E - Refusing to give a medication if the nurse believes it is unsafe demonstrates advocacy for the patient's well-being and adherence to the principles of safe medication administration.
Choices C and D are incorrect because nurses should not prescribe or change medication doses without proper authorization from a prescribing healthcare provider. It is beyond the scope of a nurse's role.
In summary, the correct answers focus on patient safety, monitoring effectiveness, and advocating for the patient's best interest, while the incorrect choices involve actions outside the nurse's scope
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? Select all.
- A. Urinary incontinence
- B. Diarrhea
- C. Bradypnea
- D. Orthostatic hypotension
- E. Nausea
Correct Answer: C, D, E
Rationale: The correct answers are C, D, and E. Opioid analgesics can cause respiratory depression (bradypnea), leading to shallow breathing. Orthostatic hypotension is a potential side effect due to vasodilation. Nausea is common with opioid use as they can stimulate the chemoreceptor trigger zone. Urinary incontinence (A) and diarrhea (B) are not typically associated with opioid analgesics. So, the nurse should anticipate monitoring for bradypnea, orthostatic hypotension, and nausea as potential adverse effects.
A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?
- A. Macaroni & cheese
- B. Fresh fruit & whole wheat toast
- C. Rice pudding & ripe bananas
- D. Roast chicken & white rice
Correct Answer: B
Rationale: The correct answer is B: Fresh fruit & whole wheat toast. Fresh fruits are high in fiber, which aids in digestion and helps prevent constipation. Whole wheat toast also contains fiber, promoting regular bowel movements. Macaroni & cheese (A) and rice pudding & ripe bananas (C) are low in fiber and may worsen constipation. Roast chicken & white rice (D) lack sufficient fiber to alleviate constipation.
An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question?
- A. Assisting a client who is 24hr postop to use an incentive spirometer
- B. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift
- C. Providing nasopharyngeal suctioning for a client who has pneumonia
- D. Replacing the cartridge and tubing on a PCA pump
Correct Answer: D
Rationale: The LPN should question assignment D (replacing the cartridge and tubing on a PCA pump) because this task involves medication administration and intravenous therapy, which are typically outside the LPN's scope of practice. LPNs are not trained to handle complex medication delivery systems like PCA pumps, as this requires specialized knowledge and skills that are within the RN's scope of practice. It is crucial for patient safety that tasks are assigned to healthcare providers based on their education, training, and scope of practice to prevent errors and ensure quality care. Assignments A, B, and C are within the LPN's scope of practice and can be safely performed without questioning.
A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development?
- A. Becoming actively involved in providing guidance to the next generation
- B. Adjusting to major changes in roles and relationships due to losses
- C. Devoting a great deal of time to establishing an occupation
- D. Finding oneself 'sandwiched' in between & being responsible for two generations
Correct Answer: C
Rationale: The correct answer is C: Devoting a great deal of time to establishing an occupation. This is an example of appropriate psychosocial development for a young adult as per Erikson's theory of psychosocial development. During the stage of young adulthood, individuals focus on establishing their careers and personal identities. This is a crucial developmental task during this stage, as it helps individuals gain a sense of purpose and direction in life. Choices A, B, and D involve responsibilities and challenges more commonly associated with other stages of life, such as middle adulthood or late adulthood. Therefore, they are not appropriate examples of psychosocial development for a young adult.