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The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Assigning which of these tasks to a UAP indicates the student needs further teaching about the delegation process?
- A. Assist a client post cerebral vascular accident to ambulate
- B. Feed a 2 year-old in balanced skeletal traction
- C. Care for a client with discharge orders
- D. Collect a sputum specimen for acid fast bacillus
Correct Answer: C
Rationale: Care for a client with discharge orders. A registered nurse (RN) is the best person to do teaching or evaluation that is needed at time of discharge.
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The nurse manager overhears multiple conversations on a hospital unit. Based on the statement made, the nurse manager should initiate the process for reporting incivility with which person?
- A. Charge nurse to the nurse, "I need to discuss the medication error you made yesterday."
- B. HCP to the nurse, "Tell me again what the client's vital signs were before I collapsed."
- C. Nurse to a coworker, "You forgot to document the client's noon glucometer reading."
- D. HCP to the client, "I can't do anything more for you; you don't follow my advice anyway."
Correct Answer: D
Rationale: The HCP's statement to the client is demeaning and uncivil, warranting a report for incivility.
The nurse is to administer a new medication to a client. Which of these actions best demonstrate awareness of safe, proficient nursing practice?
- A. Verify the order for the medication. Prior to giving the medication the nurse should say, 'Please state your name.'
- B. Upon entering the room the nurse should ask: 'What is your name? What allergies do you have?' and then check the client's name band and allergy band.
- C. As the room is entered say 'What is your name?' then check the client's name band.
- D. Verify the client's allergies on the chart and confirm the client's name on the name band.
Correct Answer: B
Rationale: Asking the client to state their name and allergies, then verifying with the name band and allergy band, ensures accurate identification and safety.
A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?
- A. Explain to the client that the dentures must come out as they may get lost or broken in operating room
- B. Ask the client if there are second thoughts about having the procedure
- C. Notify the anesthesia department and the surgeon of the client's refusal
- D. Ask the client if the preference would be to remove the dentures in the operating room receiving area
Correct Answer: D
Rationale: Ask the client if the preference would be to remove the dentures in the operating room receiving area. Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client's sense of self-esteem and self-concept.
The client with a right femoral arterial line is confused, thrashing about in bed, and picking at the tubing. The HCP prescribes wrist restraints. Based on this information, what should the nurse plan to do?
- A. Apply the wrist restraints as prescribed
- B. Request an order for a right ankle restraint also
- C. Request an order for sedation instead of restraints
- D. Question the order; restraints will increase the client's agitation
Correct Answer: B
Rationale: An ankle restraint is needed to prevent leg movement that could dislodge the femoral arterial line, which wrist restraints alone cannot address.
A newborn has been delivered. An Apgar score is given. What does this scoring system indicate?
- A. heart rate, respiratory effort, color, muscle tone, reflex irritability
- B. heart rate, bleeding, cyanosis, edema
- C. bleeding, reflex, edema
- D. respiratory effort, heart rate, seizures
Correct Answer: A
Rationale: The Apgar scoring system was put into place by Virginia Apgar, an anesthesiologist in New York, for the purpose of assessing newborns in the areas of heart rate, respiratory effort, color, muscle tone, and reflex irritability at 1, 5, and sometimes 10 minutes after birth.