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The nurse is preparing the client assignments for the day to a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which clients should the nurse assign to the LPN because of client needs that cannot be met by UAP? Select all that apply.
- A. A client requiring frequent suctioning
- B. A client requiring a dressing change to the foot
- C. A client requiring range-of-motion exercises twice daily
- D. A client requiring reinforcement of teaching about a diabetic diet
- E. A client on bed rest requiring vital sign measurement every 4 hours
- F. A client requiring collection of a urine specimen for urinalysis testing
Correct Answer: A,B,D
Rationale: Delegation is the transferring to a competent individual the authority to perform a nursing task. When the nurse plans client assignments, he or she needs to consider the educational level and experience of the individual and the needs of the client. The LPN is trained to perform all the tasks indicated in the options; the clients who have needs that cannot be met by the UAP are those requiring suctioning, a dressing change, and reinforcement of teaching about a diabetic diet. UAP are trained to perform range-of-motion exercises, measure vital signs, and collect a urine specimen.
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Which action demonstrates a situational leadership style by the nurse manager?
- A. The nurse manager delegates tasks to each team member.
- B. The nurse manager allows team members to work without supervision.
- C. The nurse manager invites team members to provide input about a unit problem.
- D. The nurse manager quickly delegates activities to team members during an emergency situation.
Correct Answer: D
Rationale: The situational leadership style uses a style depending on the situation and events. This type of leadership style is used in emergency situations when the nurse manager needs to quickly delegate activities to achieve a successful outcome for the situation. A laissez-faire leader abdicates leadership and responsibilities, allowing staff to work without assistance, direction, or supervision. Participative leadership demonstrates an 'inbetween' style, neither authoritarian nor democratic. In participative leadership, the manager presents an analysis of problems and proposals for actions to team members, inviting critique and comments. The participative leader then analyzes the comments and makes the final decision. The autocratic style of leadership is task oriented and directive.
The nurse is planning to obtain an arterial blood gas (ABG) from the radial artery of a client with a diagnosis of chronic obstructive pulmonary disease (COPD). To prevent bleeding after the procedure, which priority activity should the nurse plan time for after the arterial blood is drawn?
- A. Holding a warm compress over the puncture site for 5 minutes
- B. Encouraging the client to open and close the hand rapidly for 2 minutes
- C. Applying pressure to the puncture site by applying a 2 x 2 gauze for 5 minutes
- D. Having the client keep the radial pulse puncture site in a dependent position for 5 minutes
Correct Answer: C
Rationale: Applying pressure over the puncture site for 5 to 10 minutes reduces the risk of hematoma formation and damage to the artery. A cold compress would aid in limiting blood flow; a warm compress would increase blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site.
The nurse is preparing to administer prescribed amiodarone intravenously. To provide a safe environment, the nurse should ensure that which specific safety consideration is in place for the client before administering the medication?
- A. Oxygen therapy
- B. Oxygen saturation monitor
- C. Continuous cardiac monitoring
- D. Noninvasive blood pressure cuff
Correct Answer: C
Rationale: Amiodarone is an antidysrhythmic medication that affects cardiac rhythm. Continuous cardiac monitoring is essential to detect any adverse effects such as arrhythmias, which can be life-threatening. This ensures a safe environment for the client during administration. Oxygen therapy and oxygen saturation monitoring are not specific requirements for amiodarone administration unless indicated by the client's condition. A noninvasive blood pressure cuff is useful but not the primary safety consideration compared to cardiac monitoring.
The nurse is assessing a client with a lower leg cast who has just been measured and fitted for crutches. Which observation should help the nurse determine if the client's crutches are fitted correctly?
- A. The top of the crutch is even with the axilla.
- B. The elbow is straight when the hand is on the handgrip.
- C. The client's axilla is resting on the crutch pad during ambulation.
- D. The elbow is at a 30-degree angle when the hand is on the handgrip.
Correct Answer: D
Rationale: When using crutches, for optimal upper extremity leverage, the elbow should be at approximately 30 degrees of flexion when the hand is resting on the handgrip. The top of the crutch needs to be two to three finger widths lower than the axilla. When crutch walking, all weight needs to be on the hands to prevent nerve palsy from pressure on the axilla. Therefore, options 1, 2, and 3 are incorrect.
The nurse has applied the patch electrodes of an automatic external defibrillator (AED) to the chest of a client who is pulseless. The defibrillator has interpreted the rhythm to be ventricular fibrillation. Which priority action should the nurse prepare to implement next?
- A. Administer rescue breathing during the defibrillation.
- B. Perform cardiopulmonary resuscitation (CPR) for 1 minute before defibrillating.
- C. Charge the machine and immediately push the 'discharge' buttons on the console.
- D. Order any personnel away from the client, charge the machine, and defibrillate through the console.
Correct Answer: D
Rationale: If the AED advises to defibrillate, the nurse or rescuer orders all persons away from the client, charges the machine, and pushes both of the 'discharge' buttons on the console at the same time. The charge is delivered through the patch electrodes, and this method is known as 'hands-off' defibrillation, which is safest for the rescuer. The sequence of charges is similar to that of conventional defibrillation. Option 1 is contraindicated for the safety of any rescuer. Performing CPR delays the defibrillation attempt.