Nokea
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.
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The nurse is planning care for a client with the diagnosis of deep vein thrombosis (DVT) of the left leg. The client is experiencing severe edema and pain in the affected extremity. Which interventions should the nurse plan to implement in the care of this client? Select all that apply.
- A. Elevate the left leg.
- B. Apply moist heat to the left leg.
- C. Administer acetaminophen as prescribed.
- D. Ambulate in the hall three times per shift.
- E. Administer anticoagulation as prescribed.
Correct Answer: A,B,C,E
Rationale: Management of the client with DVT who is experiencing severe edema and pain includes bed rest; limb elevation; relief of discomfort with warm, moist heat and analgesics as needed; anticoagulant therapy; and monitoring for signs of pulmonary embolism. In current practice, activity restriction may not be prescribed if the client is receiving low-molecular-weight anticoagulation; however, some primary health care providers may still prefer bed rest for the client.
The nurse is planning care for a suicidal client who is hallucinating and delusional. Which intervention should the nurse incorporate into the nursing care plan to best assure client safety?
- A. Check the client's location every 15 minutes.
- B. Begin suicide precautions with 30-minute checks.
- C. Initiate one-to-one suicide precautions immediately.
- D. Ask the client to report suicidal thoughts immediately.
Correct Answer: C
Rationale: One-to-one suicide precautions are required for the client rescued from a suicide attempt. In this situation, additional significant information is that the client is delusional and hallucinating. Both of these factors increase the risk of unpredictable behavior, compromised judgment, and the risk of suicide. Options 1, 2, and 4 do not provide the constant supervision necessary for this client.
A registered nurse (RN) in charge of the client care unit is preparing the assignments for the day. The RN assigns unlicensed assistive personnel (UAP) to make beds and bathe one of the clients on the unit and assigns additional UAP to fill the water pitchers and serve juice to all of the clients. Another RN is assigned to administer all medications. Based on the assignments designed by the RN in charge, which nursing care delivery model is being implemented?
- A. Team
- B. Primary
- C. Functional
- D. Exemplary
Correct Answer: C
Rationale: The functional model of care involves an assembly line approach to client care, with major tasks being delegated by the charge nurse to individual staff members. Team nursing is characterized by a high degree of communication and collaboration among members. The team is generally led by an RN, who is responsible for assessing, developing nursing diagnoses, planning, and evaluating each client's plan of care. In primary nursing, concern is with keeping the nurse at the bedside actively involved in care, providing goal-directed and individualized client care. In an exemplary model of team nursing, each staff member works fully within the realm of educational and clinical experience in an effort to provide comprehensive individualized client care. Each staff member is accountable for client care and outcomes of care.
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 clinic nurse wants to develop a teaching program for clients with a diagnosis of diabetes mellitus. Which strategy should the nurse initiate first in order to best meet the clients' needs?
- A. Assess the clients' functional abilities.
- B. Ensure that insurance will pay for participation in the program.
- C. Discuss the focus of the program with the multidisciplinary team.
- D. Include everyone who comes into the clinic in the teaching sessions.
Correct Answer: A
Rationale: Nurse-managed clinics focus on individualized disease prevention and health promotion and maintenance. Therefore, the nurse must first assess the clients and their needs to effectively plan the program. Options 2, 3, and 4 do not address the clients' needs related to the diagnosis.