Nokea
Delegation of tasks to appropriate personnel allows the nurse to:
- A. take a break.
- B. keep other members of the team productive.
- C. maintain tight control of all aspects of the workflow.
- D. realize the importance of her role by making all decisions.
Correct Answer: B
Rationale: Maintaining the productivity of all team members by delegating tasks appropriate to the job descriptions of the personnel increases work effectiveness and efficiency.
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A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?
- A. Risk for Self Harm
- B. Body Image Disturbance
- C. Ineffective Role Performance
- D. Powerlessness
Correct Answer: B
Rationale: Of the nursing diagnoses listed, the client's statement most represents Body Image Disturbance because it directly refers to loss of the function of having a child. Nothing in the statement indicates that the client is at risk for harming herself. Ineffective Role Performance could be correct but is not the best choice because the statement does not reflect a disruption of the parent's role. Powerlessness could be an appropriate nursing diagnosis if the client described feeling powerless about the infertility.
The nurse is caring for a non-English speaking client. The surgeon has asked the nurse to hurry up and prepare the client for their scheduled procedure, which is running late. Which of the following is least appropriate?
- A. Explain to the client's family member that the procedure may be delayed further.
- B. Inform the surgeon that the procedure will be delayed further because getting a staff interpreter will take additional time.
- C. Allow the client's family member to serve as the interpreter.
- D. Ask if a phone-service interpreting service is available to expedite the client preparation.
Correct Answer: C
Rationale: The client's family member should not be relied on as an interpreter.
The nurse notices that a family is waiting at the nursing station desk for its loved one to be brought to the unit for admission during a change-of-shift report. The nurse should:
- A. request that the family wait for its loved one in the client's room and wait to resume the report until the family has left the desk area.
- B. request that a nursing assistant bring coffee for the family while it waits at the desk and continue with the report.
- C. request that the family have a seat in the station rather than stand while awaiting its loved one.
- D. request that the family wait for its loved one in the Emergency Department waiting room.
Correct Answer: A
Rationale: To protect the privacy of clients and the confidentiality of the information shared in a change-of-shift report, the family should be asked to wait in the client's room, and the report should be resumed only after it can no longer hear what is said.
Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?
- A. refusal to walk
- B. not pulling to a standing position
- C. negative Trendelenburg sign
- D. negative Ortolani sign
Correct Answer: B
Rationale: The nurse might be concerned about developmental dysplasia of the hip if an 11-12-month-old child doesn't pull to a standing position. An infant who does not walk by 15 months of age should be evaluated. Children should start walking between 11-15 months of age. Trendelenberg sign is related to weakness of the gluteus medius muscle, not hip dysplasia. Ortolani sign is used to identify congenital subluxation or dislocation of the hip in infants.
Which of the following is not true of clinical pathways?
- A. They need to be updated daily.
- B. They show how the client is expected to respond to their diagnosis.
- C. The goal is improvement or discharge from the facility.
- D. They are evidence based.
Correct Answer: A
Rationale: Clinical pathways may be daily or weekly, so they may not need to be updated every day.