Nokea
The charge nurse delegates the administration of a pain medication to a practical nurse. Which statement, made by the charge nurse, indicates that the final step in the delegation process has been completed?
- A. Did you document the administration of the pain medication on the medication record?
- B. Is the physician aware of the client's need for pain medication?
- C. What is the client's pain level since administering the pain medication 30 minutes ago?
- D. Have you ever administered this type of pain medication previously?
Correct Answer: C
Rationale: The final step in the delegation process is to ensure that the task has been completed and determine the resulting outcome of the action. In this case, it is ensuring the medication is given and assessing for pain relief. The other steps may be completed in the delegation process, but they are not completed last.
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The nurse is caring for a client who received a poor prognosis when the physician made rounds. The client is quiet, tearful at times, and prefers to be in a darkened room. The nurse observes a nursing assistant entering the room, turning on the lights, and stating 'Are we ready to get out of bed yet, the day is half over?' When addressing the statement of the nursing assistant, which communication technique would the nurse be most correct to discuss?
- A. Giving disapproval
- B. Belittling
- C. Using clich?©s
- D. Patronizing
Correct Answer: D
Rationale: Patronizing treats the client condescendingly as if incapable of making a decision. Giving disapproval holds the client to a rigid standard and is sarcastic in response. Belittling disregards how the client is responding as an individual and groups them with others in the similar position. Using clich?©s provides worthless advice and curtails exploring alternatives.
Which of the following is a reason why silence is considered therapeutic?
- A. It demonstrates concern or affection.
- B. It communicates caring and support.
- C. It encourages a client's verbal communication.
- D. It is therapeutic when a client is uncomfortable.
Correct Answer: C
Rationale: Silence is the art of remaining quiet. One of its therapeutic uses is to encourage a client's verbal communication. Affective touch is typically used to demonstrate concern or affection. Its intention is to communicate caring and support. The nurse uses affective touch therapeutically in many situations, including when a client is uncomfortable.
The nurse is evaluating the comprehension of a client's knowledge of the subcutaneous administration of an anticoagulant medication. Which method provides the best feedback?
- A. Having the client explain the medication and injection site
- B. Having the client demonstrate the injection technique on an orange
- C. Having the client watch the nurse prepare the medication and administer it
- D. Having the client prepare the syringe and independently administer the injection
Correct Answer: D
Rationale: Having the client prepare the syringe and independently administer the injection is the 'show back' portion of learning comprehension because it includes demonstrating the skill. By independently demonstrating, the nurse is able to evaluate the knowledge base and skill. Having the client watch the nurse administer the medication involves teaching, but not performing the skill. Having the client explain the medication and injection site or administer the injection into an orange demonstrates parts of the skill but does not allow the nurse to evaluate the entire skill.
The nurse is discharging a client with an indwelling Foley catheter. Which instructional method is best when teaching a psychomotor learner about the care necessary?
- A. Provide a booklet that outlines directions.
- B. Provide the phone number of a nursing agency to assist with care.
- C. Provide testimonials of others who have had a Foley catheter at home.
- D. Provide the Foley catheter and equipment to handle and practice care.
Correct Answer: D
Rationale: A psychomotor learner prefers to learn by doing. Providing equipment enables the learner to use the equipment and reinforces the necessary care. The booklet would be appropriate for the cognitive learner. A nursing agency is most often ordered by a physician for nursing care but is not a daily service. Testimonials are effective for affective learners.
The charge nurse in a long-term facility is addressing a breach in care with a client's family. Which body language would the family interpret as being sincere in the statement?
- A. Open hands
- B. Downcast eyes
- C. Shifting from foot to foot
- D. Steepled fingers
Correct Answer: A
Rationale: Open hands is a form of body language representing sincerity. This body language shows that the staff and facility care for the quality of care of the client and are open about the details of care. Downcast eyes convey remorse. Shifting from foot to foot denotes a desire to get away or avoid the discussion. Steepled fingers is interpreted as an authoritative approach.