Nokea
A nurse in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take a break. To ensure client safety during the break, which actions should the nurse take? Select all that apply.
- A. Asking the nursing assistant to contact the health care provider during the nurse’s break if a client’s pain medication is not effective
- B. Informing the nursing assistant that she is leaving the nursing unit to get a cup of coffee from a vending machine in the lobby
- C. Asking the nursing assistant to administer a medication placed at the client's bedside if the client awakens
- D. Conducting client rounds before taking the break
Correct Answer: D
Rationale: The nurse is responsible for ensuring client safety at all times and must not leave the nursing unit for any reason during the shift. The nurse’s break should be taken in a designated area located on the nursing unit. Before taking the break, the nurse should check all clients to ensure that they are safe and comfortable and that their needs have been met. Conducting client rounds before taking the break is crucial to assess the clients' conditions and address any immediate needs, ensuring their safety. Asking the nursing assistant to contact the health care provider during the nurse’s break is not appropriate as the nurse should handle this responsibility. Leaving the nursing unit to get coffee is not recommended as the nurse should stay within the unit to respond promptly to any client needs. Asking the nursing assistant to administer medication or make clinical decisions is outside the scope of their practice and should not be delegated.
You may also like to solve these questions
In a centralized decision-making process within an organization, where is the authority to make decisions vested?
- A. Every employee
- B. A few individuals, such as the board of directors
- C. Many individuals, with decisions filtering down to the individual employee
- D. All nursing employees, pharmacists, and hospital health care providers
Correct Answer: B
Rationale: In a centralized decision-making process within an organization, the authority to make decisions is concentrated in a few individuals, such as the board of directors. This means that key decision-making power is held by a select group at the top of the organizational hierarchy. Choices A, C, and D are incorrect because in a centralized structure, decision-making authority is not distributed among every employee, does not filter down to individual employees, and is not shared among all nursing employees, pharmacists, or hospital health care providers. Centralized decision-making implies a more top-down approach.
The nurse should teach parents of small children that the most common type of first-degree burn is:
- A. scalding from hot bath water or spills
- B. contact with hot surfaces such as stoves and fireplaces
- C. contact with flammable liquids or gases resulting in flash burns
- D. sunburn from lack of protection and overexposure
Correct Answer: D
Rationale: The most common type of first-degree burn in small children is sunburn, often due to lack of protection and overexposure to the sun. This type of burn highlights the importance of educating parents about using sunscreens and ensuring children are adequately protected from the sun's harmful rays. Choices A, B, and C describe scenarios that can lead to burns but are not the most common type of first-degree burn in small children, making them incorrect.
A nurse is planning client assignments for the day. Which task should the nurse assign to the nursing assistant (unlicensed assistive personnel)?
- A. Recording the urinary output for a client with renal calculi whose urine must be strained
- B. Dressing change instructions for a client who had a mastectomy 2 days ago
- C. Reporting abnormal lab values to the health care provider for a client scheduled for a laparoscopic cholecystectomy
- D. Preprocedural teaching for a client scheduled for a cardiac stress test
Correct Answer: A
Rationale: The nurse is legally responsible for client assignments and must assign tasks based on state nursing practice act guidelines and job descriptions provided by the employing agency. The nursing assistant is trained to measure, collect, and strain urine, making recording urinary output for a client with renal calculi a suitable task for the nursing assistant. This task falls within the nursing assistant's role description. Dressing change instructions for a client who had a mastectomy involve a higher level of skill and knowledge, beyond the scope of a nursing assistant. Reporting abnormal lab values to the health care provider for a client scheduled for a laparoscopic cholecystectomy requires interpretation and clinical judgment, which is typically not within the nursing assistant's role. Preprocedural teaching for a client scheduled for a cardiac stress test involves providing detailed information and education, which is usually the responsibility of a licensed nurse or other qualified healthcare provider.
A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which action reflects the use of evidence-based practice in the care of the client?
- A. Keeping the door to the client's room closed
- B. Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all times
- C. Placing the client in a semiprivate room with a cohort client
- D. Using a surgical mask when entering the client's room
Correct Answer: A
Rationale: Evidence-based practice is an approach to client care that integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care. In the case of pulmonary tuberculosis, which is transmitted through the airborne route, keeping the door to the client's room closed is crucial to prevent the spread of infection. Placing the client in a semiprivate room with a cohort client is not recommended for airborne precautions; a private room is required to prevent transmission. Fitting the client for an N95 or HEPA mask is essential for the nurse's protection when entering the room, not for the client to wear at all times. Using a surgical mask when entering the client's room is not sufficient for airborne precautions; an N95 or HEPA mask is necessary.
A client has experienced a CVA with right hemiparesis and is ready for discharge from the hospital to a long-term care facility for rehab. To provide optimal continuity of care, the nurse should do all of the following except:
- A. document the current functional status
- B. have the physician fax a report to the receiving facility
- C. copy appropriate parts of the medical record for transport to the receiving facility
- D. phone a report to the facility
Correct Answer: B
Rationale: To ensure optimal continuity of care for a client transitioning to a long-term care facility for rehab after a CVA, the nurse plays a crucial role in communication. Documenting the current functional status is essential for the receiving facility to plan appropriate care. Copying relevant parts of the medical record for transport provides important background information. Phoning a report directly to the facility is a direct and effective way to communicate the client's condition and care plan. However, having the physician fax a report to the receiving facility introduces an extra step that may delay essential information transfer and increase the risk of miscommunication. Therefore, it is not the optimal choice for ensuring seamless continuity of care.