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.
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.
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.
The nurse instructs a client with a diagnosis of atrial fibrillation who has been prescribed warfarin to use an electric razor for shaving. Which premise best supports the rationale for this instruction?
- A. Cuts need to be avoided.
- B. Any cut may cause infection.
- C. Electric razors can be disinfected.
- D. All straight razors contain bacteria.
Correct Answer: A
Rationale: Clients with atrial fibrillation are placed on anticoagulants to prevent thrombus formation and possible stroke. Therefore, measures to prevent bleeding need to be taught to the client. The importance of use of an electric razor is to prevent cuts and possible bleeding. Not all cuts cause infection. Electric razors can be cleaned but usually cannot be disinfected. Not all straight razors contain bacteria. Additionally, options 2, 3, and 4 are all unrelated to the subject of bleeding; rather, they relate to infection.