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An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?
- A. How long have you been a UAP and what units you have worked on?
- B. What type of care do you give on the surgical unit and what ages of clients?
- C. What is your comfort level in caring for children and at what ages?
- D. Have you reviewed the list of expected skills you might need on this unit?
Correct Answer: D
Rationale: The UAP must be competent to accept the delegated task. Review of skills needed versus level of performance is the most efficient and effective way to determine this.
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The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client
- A. has had a change in respiratory rate by an increase of 2 breaths
- B. has had a change in heart rate by an increase of 10 beats
- C. was minimally responsive to voice and touch
- D. has had a blood pressure change by a drop in 8 mmHg systolic
Correct Answer: C
Rationale: A change in level of consciousness indicates delirium related to acute illness. This would require the assessment of a nurse. The other changes could occur within the range of normal fluctuations.
The nurse confides to a coworker that when reporting a change in the client's condition to the HCP, the HCP stated, "It seems that every time you work, there is some catastrophe. Can't you problem-solve earlier so this doesn't happen!" What is the coworker's best response?
- A. "This HCP responds to everyone the same. You did everything right; don't feel bad."
- B. "You should obtain our hospital policy and initiate the steps to report the HCP."
- C. "Let the nurse manager know; I think our manager is already dealing with the HCP."
- D. "Let's go to the medical director, who should be told about this HCP's angry response."
Correct Answer: B
Rationale: Reporting the HCP's uncivil behavior per hospital policy is the best response to address and document the issue appropriately.
The nurse is teaching the client with a latex allergy about home and personal safety. Which information should the nurse emphasize? Select all that apply.
- A. Remove items in the home made from synthetic materials.
- B. Keep emergency telephone numbers readily accessible.
- C. Have someone remove any latex balloons and rubber bands.
- D. Avoid foods such as kiwi, bananas, avocados, and chestnuts.
- E. Certain plants, such as poinsettia plants, help remove allergens.
Correct Answer: B,C,D
Rationale: B: Emergency numbers are critical for anaphylaxis. C: Latex items like balloons and rubber bands must be removed to avoid exposure. D: Certain foods can trigger cross-reactive allergic reactions. A and E are incorrect as synthetic materials are safe, and poinsettias can cause reactions.
After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
- A. abdominal x-ray
- B. auscultation
- C. flushing tube with saline
- D. aspiration for gastric contents
Correct Answer: A
Rationale: abdominal x-ray. Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways.
A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia (MRSA). What type of isolation is most appropriate for this client?
- A. Reverse
- B. Airborne
- C. Standard precautions
- D. Contact
Correct Answer: D
Rationale: Contact precautions or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected.