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A nurse is supervising a newly licensed nurse who is caring for a client on a behavioral health unit. Complete the following sentence by using the list of options.
- A. provide continuous monitoring of this client
- B. assess for readiness for release from seclusion
- C. clearly document reason for seclusion then obtain provider prescription for seclusion or restraints
- D. provide means for hygiene and elimination
- E. discuss reason for seclusion with client
- F. offer food and fluids
Correct Answer: A,C
Rationale: The correct answers are A and C. A is important to ensure the safety and well-being of the client, especially in a behavioral health unit where close monitoring is crucial. C is necessary to ensure proper documentation and adherence to protocols when seclusion or restraints are used. B is incorrect as assessing readiness for release from seclusion should only be done by a qualified provider. D is important but not as urgent as continuous monitoring. E is not appropriate as discussing the reason for seclusion with the client may not be beneficial during an acute episode. F is important but providing food and fluids should not be the priority over continuous monitoring and proper documentation.
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A nurse manager is reviewing the unit's compliance with infection control protocols. Which of the following findings requires immediate intervention?
- A. An assistive personnel wears gloves while feeding a client.
- B. A nurse uses hand sanitizer before entering a client's room.
- C. A nurse reuses a disposable gown after leaving a client's room.
- D. A client's visitor washes their hands upon entering the room.
Correct Answer: C
Rationale: Reusing a disposable gown violates infection control protocols, as it risks cross-contamination. The other actions align with or exceed standard infection control practices.
A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes an incident report, which of the following actions should the nurse take?
- A. Make a copy of the incident report for the provider.
- B. Submit the incident report to the risk manager.
- C. Place the incident report in the client's chart.
- D. Document in the chart that an incidence report has been filed.
Correct Answer: B
Rationale: The correct answer is B: Submit the incident report to the risk manager. This is the appropriate action because the risk manager is responsible for analyzing incidents to identify potential risks and implementing strategies to prevent them in the future. Providing the report to the risk manager allows for a comprehensive review and implementation of necessary measures.
Choice A is incorrect because making a copy of the incident report for the provider does not ensure that the incident is properly analyzed and addressed. Choice C is incorrect as placing the incident report in the client's chart may not reach the appropriate personnel for further action. Choice D is incorrect because simply documenting in the chart that a report has been filed does not facilitate a comprehensive review by the risk management team.
A nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the changes?
- A. Compare the number of medication errors before and after the action was implemented.
- B. Conduct a study about the time and money costs of implementing the change.
- C. Establish a benchmark to identify a standard of performance.
- D. Provide the staff with a questionnaire to quantify staff satisfaction with the changes.
Correct Answer: A
Rationale: The correct answer is A: Compare the number of medication errors before and after the action was implemented. This method is effective in evaluating the success of the changes because it directly assesses the impact of the implemented measures on reducing medication errors. By comparing the number of errors before and after the changes, the nurse can determine if the interventions were successful in achieving the desired outcome.
Summary:
B: Conducting a study about the time and money costs is irrelevant to evaluating the success of reducing medication errors.
C: Establishing a benchmark is important for setting a standard but does not directly assess the effectiveness of the changes.
D: Providing staff with a questionnaire assesses satisfaction, not the actual impact on medication errors.
A charge nurse is working with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care?
- A. Tell other nurses what an effective team member the AP is.
- B. Detail the AP's contributions to the nurse manager.
- C. Nominate the AP for the Employee of the Month award.
- D. Give positive feedback directly to the AP.
Correct Answer: D
Rationale: The correct answer is D: Give positive feedback directly to the AP. This is the first action the nurse should take because it directly acknowledges and reinforces the AP's contributions. Providing feedback directly shows appreciation and motivates the AP to continue their excellent work. It helps build a positive relationship and boosts morale.
Choice A is less effective as it does not directly recognize the AP's efforts and may not reach the AP. Choice B involves an intermediary and may delay recognition. Choice C is a formal recognition and may not provide immediate feedback to the AP. Thus, giving direct positive feedback to the AP is the most immediate and impactful way to recognize their contributions.
A nurse is planning to delegate tasks to a licensed practical nurse (LPN). Which of the following entities is important for the nurse to understand when delegating tasks to the LPN?
- A. The National Council of State Boards of Nursing Decision Tree
- B. The state Nurse Practice Act
- C. The Omnibus Budget Reconciliation Act of 1987
- D. The National Association for Practical Nurse Education and Services
Correct Answer: B
Rationale: The correct answer is B: The state Nurse Practice Act. The Nurse Practice Act outlines the scope of practice and legal responsibilities for nurses in each state. When delegating tasks to an LPN, the nurse must adhere to the regulations and guidelines set forth in the Nurse Practice Act to ensure safe and appropriate delegation. Understanding this act is crucial to prevent legal and ethical violations.
Incorrect Choices:
A: The National Council of State Boards of Nursing Decision Tree - While this resource provides guidance on delegation, the Nurse Practice Act holds legal authority.
C: The Omnibus Budget Reconciliation Act of 1987 - This act relates to healthcare financing and does not specifically address the delegation of tasks to LPNs.
D: The National Association for Practical Nurse Education and Services - This organization focuses on education and services for LPNs but does not dictate legal guidelines for delegation.