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During the admission process of a client being admitted for surgery, the client asks the nurse if a living will, prepared 3 years ago, remains in effect. Which response is most appropriate for the nurse to provide the client?
- A. Yes, a living will never expires.
- B. You need to speak with an attorney.
- C. I will call someone to answer your question.
- D. If it accurately reflects your situation and wishes.
Correct Answer: D
Rationale: The client should discuss the living will with the primary health care provider (HCP) on a regular basis to ensure that it contains the client's current wishes and desires based on the client's current health status. Option 1 is incorrect. Although the client can consult an attorney if the living will must be changed, the accurate nursing response is to tell the client that a living will should be reviewed. Option 3 is not at all helpful to the client and is, in fact, a communication block and places the client's question on hold.
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The nurse is delegating unit nursing tasks for the day. Which tasks should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
- A. Deliver fresh water to clients.
- B. Empty urine out of Foley bags.
- C. Take temperatures, pulses, respirations, and blood pressures.
- D. Count the substance control medications in the opioid medication supply.
- E. Check the crash cart (cardiopulmonary resuscitation cart) for necessary supplies using a checklist.
- F. Check all intravenous (IV) solution bags on clients receiving IV therapy for the remaining amounts of solution in the bags.
Correct Answer: A,B,C
Rationale: Delegation is the transfer of responsibility for the performance of an activity or task while retaining accountability for the outcome. When delegating an activity, the nurse must consider the educational preparation and experience of the individual. The UAP is trained to perform noninvasive tasks and those that meet basic client needs. The UAP is also trained to take vital signs. Therefore, the appropriate activities to assign to the UAP would be to deliver fresh water to clients; empty urine out of Foley bags; and take temperatures, pulses, respirations, and blood pressures. Although the UAP is trained in performing cardiopulmonary resuscitation, the UAP is not trained to check a crash cart, and this activity must be assigned to a licensed nurse. Any activities related to medications and IV therapy must be delegated to a licensed nurse.
Which actions are most appropriate for the nurse to take in the event of an accidental poisoning in a child? Select all that apply.
- A. Save vomitus for laboratory analysis.
- B. Place the child in a flat supine position.
- C. Induce vomiting if a household cleaner was ingested.
- D. Assess for airway patency, breathing, and circulation.
- E. Determine the type and amount of substance ingested.
- F. Remove any visible materials from the nose and mouth.
Correct Answer: A,D,E,F
Rationale: In the event of accidental poisoning, the poison control center is called before attempting any interventions. Additional interventions in an accidental poisoning include saving vomitus for laboratory analysis, which may assist with further treatment; assessing for airway patency, breathing, and circulation; determining the type and amount of substance ingested if possible to identify an antidote; removing any visible materials from the nose and mouth to terminate exposure; and positioning the victim with the head to the side to prevent aspiration of vomitus and assist in keeping the airway open. Vomiting is never induced in an unconscious person or one who is experiencing seizures because of the risk of aspiration. Additionally, vomiting is not induced if lye, household cleaners, hair care products, grease or petroleum products, or furniture polish was ingested because of the risk of internal burns.
When the nurse manager encourages staff to provide input in the decision-making process, which leadership style is being demonstrated?
- A. Autocratic
- B. Situational
- C. Democratic
- D. Laissez-faire
Correct Answer: C
Rationale: The democratic style of leadership best empowers staff toward excellence because this style of leadership allows nurses to provide input regarding the decision-making process and an opportunity to grow professionally. The autocratic style of leadership is task oriented and directive. The leader uses his or her power and position in an authoritarian manner to set and implement organizational goals. Decisions are made without input from the staff. The situational leadership style uses a style depending on the situation and events. The laissez-faire style allows staff to work without assistance, direction, or supervision.
The nurse is caring for a client with a diagnosis of a C-6 spinal cord injury during the spinal shock phase. Which action should the nurse implement when preparing the client to sit in a chair?
- A. Apply knee splints to stabilize the joints during transfer.
- B. Teach the client to lock the knees during the pivoting stage of the transfer.
- C. Administer a vasodilator in order to improve circulation of the lower limbs.
- D. Raise the head of the bed slowly to decrease orthostatic hypotensive episodes.
Correct Answer: D
Rationale: Spinal shock is a sudden depression of reflex activity in the spinal cord that occurs below the level of injury (areflexia). It is often accompanied by vasodilation in the lower limbs, which results in a fall in blood pressure upon rising. The client can have dizziness and feel faint. The nurse should provide for a gradual progression in head elevation while monitoring the blood pressure. The use of splints would impair the transfer. Clients with cervical cord injuries cannot lock their knees. A vasodilator would exacerbate the problem.
The nurse is planning activities for a client diagnosed with depression who was just admitted to the hospital. Which therapeutic action should be implemented as part of the nurse's plan?
- A. Provide an activity that is quiet and solitary in nature.
- B. Plan nothing until the client asks to participate in the milieu.
- C. Offer the client a menu of activities and insist that the client participate in all of them.
- D. Provide a structured daily program of activities and encourage the client to participate.
Correct Answer: D
Rationale: A depressed person is often withdrawn. In addition, the person experiences difficulty concentrating, loss of interest or pleasure, low energy and fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide stimulation in a structured environment. Options 1 and 2 are restrictive and offer little or no structure and stimulation. The nurse should not insist that a client participate in all activities.