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A patient is being transferred from the intensive care unit (ICU) to a medical-surgical unit. What is the responsibility of the ICU nurse during the transfer of care?
- A. Providing a verbal report to the nurse on the new unit
- B. Giving a detailed written report to the unit secretary
- C. Delegating the responsibility for providing information
- D. Making a copy of the patient's medical record
Correct Answer: A
Rationale: The transferring (ICU) nurse gives a verbal report on the patient's condition and nursing care needs to the receiving nurse. This information should not be given to a unit secretary, nor can this be delegated to others. The medical record is transferred with the patient; a copy is not made for transfers within the agency.
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A nurse on a medical-surgical unit is teaching a patient's family about hospice care. How does the nurse best explain the focus of this care?
- A. Hospice care focuses on symptom and pain relief.
- B. Nutrition is provided orally or by tube to maintain intake.
- C. Surgical procedures are performed when medically necessary.
- D. Services are provided until the patient's death.
Correct Answer: A
Rationale: Hospice services include pain management, physician and nurse practitioner services, spiritual support, respite services, and bereavement counseling.
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.
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.
A home health nurse is scheduled to visit a patient recently discharged from the hospital with a new colostomy. During the entry phase of the home visit, what actions will the nurse perform? Select all that apply.
- A. Collect information about the patient's diagnosis, surgery, and treatments
- B. Call the patient to make initial contact and schedule a visit
- C. Develop rapport with the patient and their family
- D. Assess the patient to identify their needs
- E. Assess the physical environment of the home
- F. Evaluate safety issues including the neighborhood in which the patient lives
Correct Answer: C,D,E
Rationale: In the entry phase of the home visit, the nurse develops rapport with the patient and family, makes assessments, determines nursing diagnoses, establishes desired outcomes, plans and implements prescribed care, and provides teaching. In the pre-entry phase of the home visit, the nurse collects information about the patient's diagnoses, surgical experience, socioeconomic status, and treatment orders. In the pre-entry phase, the nurse also gathers supplies needed, makes an initial phone contact with the patient to arrange for a visit, and assesses the patient's neighborhood for safety issues.
A nurse is reviewing the discharge plan with a patient who had major abdominal surgery. Which statement by the nurse is most appropriate?
- A. I'll bet you will be so glad to be home and sleep in your own bed.
- B. Tell me about your understanding of your recovery needs after discharge.
- C. Be sure to take your pain medications and change your dressing.
- D. You will just be fine! Please stop worrying.
Correct Answer: B
Rationale: The purpose of discharge planning is to ensure for continuity of care for the patient and family needs. The nurse uses open-ended assessment questions to begin a planning session. Essential components of discharge planning include assessing the strengths and limitations of the patient, the family or support person, and the environment; implementing and coordinating the care plan; considering individual, family, and community resources; and evaluating the effectiveness of care. Answers a and c are examples of communication or interventions, which may be included after an assessment. The statement 'You will just be fine! Please stop worrying,' is a clich?© and is avoided.