Nokea
According to the National Council of State Boards of Nursing, which of the following are included in the five rights of delegation? Select all that apply.
- A. Right task
- B. Right circumstance
- C. Right person
- D. Right direction and communication
Correct Answer: A, B, C, D
Rationale: The five rights of delegation per NCSBN include right task (A), circumstance (B), person (C), direction/communication (D), and supervision (not listed). All listed options are correct.
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The nurse is caring for a client requesting to leave against medical advice. The nurse barricades the client in their room because they feel that the client is not safe to go home. The nurse is demonstrating
- A. false imprisonment.
- B. malpractice.
- C. negligence.
- D. invasion of privacy.
Correct Answer: A
Rationale: Barricading a client (A) constitutes false imprisonment, as it unlawfully restricts their freedom. Malpractice (B) involves substandard care, negligence (C) requires harm from a breach of duty, and invasion of privacy (D) involves unauthorized disclosure.
The emergency department (ED) is caring for a client with a pulse (P) of 42, blood pressure (BP) of 90/60 mm Hg, and reports dizziness. Which of the following actions is the priority?
- A. Obtain an order for a chest radiograph (x-ray)
- B. Review the client's current medications
- C. Perform a focused neurological assessment
- D. Obtain a 12-lead electrocardiogram (ECG)
Correct Answer: D
Rationale: A pulse of 42 with hypotension and dizziness (D) suggests symptomatic bradycardia, requiring an immediate ECG to identify arrhythmias, per ACLS guidelines. Chest x-ray (A), medication review (B), and neurological assessment (C) are secondary to cardiac evaluation.
The nurse is planning client assignments in the mental health unit. Which task should the nurse delegate to the licensed practical/vocational nurse (LPN/VN)?
- A. conduct a suicide assessment on a newly admitted client
- B. administering prescribed lithium to a client with bipolar disorder
- C. leading a group therapy session for clients with depressive disorders
- D. monitoring a client who is talking on the phone to a family member
Correct Answer: B
Rationale: Administering prescribed lithium (B) is within the LPN’s scope, involving medication administration to a stable client. Suicide assessment (A) and group therapy (B) require RN expertise, and monitoring phone calls (C) is a UAP task, making these inappropriate for LPN delegation (D).
The nurse has been made aware that the following clients require assistance. The nurse should first assist the client
- A. experiencing a flare-up of ulcerative colitis and has had 2 bloody bowel movements in the past hour.
- B. with a cerebral aneurysm, has developed nausea and vomiting.
- C. taking prescribed prednisone for an allergic reaction and reports indigestion.
- D. being treated for Bell's palsy and reports ringing in their ears.
Correct Answer: A
Rationale: Bloody bowel movements in ulcerative colitis (A) suggest active bleeding, requiring immediate assistance to prevent hypovolemia. Nausea with aneurysm (B), indigestion with prednisone (C), and tinnitus with Bell’s palsy (D) are less urgent.
The nurse is planning a staff education program about conflict resolution strategies. Which of the following would be an effective strategy in conflict resolution?
- A. Attempt to compare the person or situation to other people and situations.'
- B. Avoiding the conflict may ease frustration for those involved.'
- C. The goal of conflict resolution is to create a win-win situation for all.'
- D. Passively listen as individuals express themselves.'
Correct Answer: C
Rationale: Aiming for a win-win situation (C) is an effective conflict resolution strategy, promoting mutual benefit and collaboration. Comparing situations (A) is unhelpful, avoidance (B) delays resolution, and passive listening (D) lacks active engagement.