Vanyo Final Exam

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1

What should the nurse know when observing and interpreting a patient's nonverbal communication?

  1. Patients are usually aware of their nonverbal cues
  2. Verbal responses are more important than nonverbal cues
  3. Nonverbal cues have obvious meaning and are easily interpreted
  4. Nonverbal cues provide significant information and need to be validated.

Rationale: Answer D. Non-verbal communication is very powerful; however, the nurse must validate that the message perceived is the intended message.

2

A patient asks the nurse, “When can I go smoke a cigarette?” the patient is told that they cannot smoke while in the hospital. The nurse offers the patient a nicotine patch but the patient refuses. The nurse then walks in the room to find the patient attempting to light a cigarette. Which Patient’s Bill of Responsibilities is being broken?

  1. Responsibility to provide feelings, health, history, and medications
  2. Responsibility to answer questions and cooperate with health team
  3. Responsibility to be respectful of others and try to modify lifestyle
  4. Responsibility to accept the consequences if health plan is not followed

Rationale: Answer C. Smoking is a lifestyle change that must be modified in order for the healthcare team to provide the safest care to the patient. It is the patients’ responsibility to temporarily modify that aspect of their lifestyle.

3

The nurse notes that an advance directive is in the client’s medical record. Which of the following statements represents the best description of guidelines a nurse would follow in this case?

  1. A durable power of attorney for health care is invoked only when the client has a terminal condition or is in a persistent vegetative state.
  2. A living will allows an appointed person to make health care decisions when the client is in an incapacitated state.
  3. A living will is invoked only when the client has a terminal condition or is in a persistent vegetative state.
  4. The client cannot make changes in the advance directive once the client is admitted into the hospital.

Rationale: Answer C. A living will directs the client’s healthcare in the event of a terminal illness or condition. A durable power of attorney is invoked when the client is no longer able to make decisions on his or her own behalf. The client may change an advance directive at any time.

4

Nurses agree to be advocates for their patients. Practice of advocacy calls for the nurse to:

  1. Seek out the nursing supervisor in conflicting situations.
  2. Work to understand the law as it applies to the client's clinical condition.
  3. Assess the client's point of view and prepare to articulate this point of view.
  4. Document all clinical changes in the medical record in a timely manner.

Answer C. Rationale: Nurses strengthen their ability to advocate for a client when nurses identify personal values and then accurately identify the values of the client and articulate the client's point of view.

5

A nurse discovers that a primary care provider has prescribed an unusually large dosage of a medication. Which is the most appropriate action?

  1. Administer the medication
  2. Notify the prescriber
  3. Call the pharmacist.
  4. Refuse to administer the medication.

Answer #2. Rationale: The nurse should call the person who wrote the order for clarification. Administering the medication is incorrect because knowing the dose is outside the normal range and not questioning it could lead to client harm and liability for the nurse.

6

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for patients. The nurse has never worked in the ICU. The nurse should take which action?

  1. A) Refuse to float to the ICU based on lack of unit orientation.
  2. B) Clarify with the team leader to make a safe ICU client assignment.
  3. C) Ask the nursing supervisor to review the hospital policy on floating.
  4. D) Submit a written protest to nursing administration, and then call the hospital lawyer.

Rationale: B. Floating is an acceptable practice used by hospitals. Legally, the nurse cannot refuse to float unless there is a union contract in place stating that the nurse cannot work in specified areas or the nurse can prove the lack of knowledge for the performance of assigned tasks. Clarifying the client assignment with the team leader to ensure safety is the best option.

7

The nurse made an error in a narrative documentation of an assessment finding on a client and obtained the client’s record to correct the error. The nurse should take which action to correct the error? Select all that apply.

  1. A) Document the correction as a late entry in the client’s record.
  2. B) Draw one line through the error, initialing and dating it.
  3. C) Try to erase the error for space to write in the correct data.
  4. D) Use whiteout to delete the error to write in the correct data.
  5. E) Write a concise statement to explain why the correction is needed.
  6. F) Document the correct information and end with the nurse’s signature and title

Rationale: B, F. If the nurse makes an error in narrative documentation in the client’s record, the nurse should follow agency policies to correct the error. This includes drawing on a line through the error, initialing and dating the line, and then documenting the correct data. A late entry is used to document additional information not remembered at the initial time of documentation, not for corrections. Documenting the correct information with the nurse’s signature and title is correct. Erasing data from a client’s record and the use of white out are prohibited.

8

These are effective ways to be a patient advocate except:

  1. A) Work with community agencies and lay practitioners.
  2. B) Applying personal beliefs of the institution to care for patients.
  3. C) Be assertive.
  4. D) Communicate with government agencies that may have authority to do something about the client’s needs.

Rationale: B. The patient’s rights and beliefs should always take precedence when they conflict with those of a healthcare provider. All other options are actions of an effective patient advocate. (Pg 2557)

9

The clinic nurse is preparing to explain the concepts of Kohlberg’s theory of moral development to a parent. The nurse should tell the parent that which factor motivates good and bad actions for a child at the preconventional level?

  1. A) Peer pressure
  2. B) Social pressure
  3. C) Parent’s behavior
  4. D) Punishment and reward

Rationale: D. In the preconventional stage, morals are thought to be motivated by punishment and reward. Actions are seen as good or bad. Options A, B, and C are not associated with this stage of moral development. (Pg 1658)

10

The nurse is using SBARR to effectively communicate with the physician. The nurse states “He has a temperature of 101°F, HR of 110bpm, and crackles heard in the lungs bilaterally.” Which part of SBARR is the nurse conducting?

  1. Situation
  2. Recommendation
  3. Assessment
  4. Reasoning

Answer: C. Assessment. Rationale: The nurse is telling the doctor the abnormal observations made through assessment of the patient. The nurse is not explaining who they are calling about and why (situation), or recommending any actions to be taken. Lastly, “reasoning” is not an action of SBARR. SBARR stands for situation, background, assessment, recommendation, read back.

11

A hospitalized patient diagnosed with end-stage cancer has suddenly decided to discontinue treatment. The patient requests no additional treatment, such as antibiotics, tube feedings, and mechanical ventilation. When acting as the patient’s advocate, which action should the nurse take?

  1. Respect the patient’s wishes and indicate those wishes on the plan of care.
  2. Encourage the patient to share the decision with the family and the patient’s physician.
  3. Clarify other treatments that the client wishes to withhold.
  4. Wait until additional treatment is required and then decide what to do based on the patient’s condition.

Answer: B. Encourage the patient to share the decision with the family and the patient’s physician. Rationale: When advocating for the patient the nurse should encourage the patient to share with family and physician. The patient is still able to make his or her own decisions, which will be better supported when the patient shares with the physician and family.

12

An 80-year-old patient who has end stage renal failure tells the nurse that they wish to have a Do Not Resuscitate (DNR) order. Which ethical principle is the nurse upholding by supporting this decision?

  1. Nonmaleficence
  2. Beneficence
  3. Autonomy
  4. Confidentiality

Answer: C. Autonomy. Rationale: Autonomy is the right to make you own decisions. The nurse is respecting the patient’s wishes by supporting their decision.

13

A patient that is receiving end of life care is not fully conscious. When his next dose of morphine is coming up what should the nurse do?

  1. The nurse should administer the medication as indicated.
  2. The nurse should call the doctor and tell him/her that the patient is not fully conscious.
  3. The nurse should withhold the dose of medication.
  4. The nurse should administer another form of pain medication.

Answer: A. Rationale: Experts believe that care for someone who is dying should focus on relieving pain without worrying about possible long-term problems of drug dependence or abuse. Don’t be afraid of giving as much pain medicine as is prescribed by the doctor. Pain is easier to prevent than to relieve and severe pain is hard to manage.

14

The nurse is aware that end-of-life planning is often neglected because __________. (Select all that apply.)

  1. there is a clear procedure to follow.
    1. people are uncomfortable talking about death. 

    2. young people do not see the need for end-of-life planning. 

    3. end-of-life planning is a relative new concept.

    4. many persons are not sure what they want to do.

ANSWERS: b, c, d, e. Rationale: The options are so numerous that there is not any one clear line of action to follow. End-of-life planning is a relatively new concept that the older generation did not experience in their youth. Persons are reluctant to talk about death issues, especially young persons, who do not see the need.

15

The nurse is caring for an adult client who is refusing treatment that his family is insisting he receive. Which actions should the nurse take? Select all that apply.

A.) Provide support to each family member and enhance the family support system.

B.) Respect the clients’ decision concerning their own care.

C.) Tell the family that you will reason with client, assure them that you can help the client to change their mind.

D.) Follow hospital policies.

Answers: A., B., and D. Rationale: Providing false assurance to family members is neither supportive to them nor is it respecting the clients’ autonomy. Hospital policies should always be followed (Pearson, 2015. p 2569).

16

A patient who is very ill requires a blood transfusion to survive and recover fully. The patient refuses the blood transfusion and states that taking it would be against her religion. What action should the nurse take?

  1. Get consent from a family member.
  2. Communicate to the patient the risks and let the physician know the patient's wishes.
  3. Give the blood transfusion anyway.
  4. Discharge patient from hospital.

Answer: B. Rationale: One of the values basic to client advocacy is knowing that “the client is a holistic, autonomous being who has the right to make choices and decisions” (Pearson, 2015. p 2556).

17

A new mother of an infant in the NICU tells you she does not like the treatment plan the physician came up with but is too scared to tell him. What is the best step to take?

  1. A) Determine why the mother does not like the treatment plan and help her talk to the physician.
  2. B) Explain to the mother why this is the best treatment plan for the infant.
  3. C) Tell the mother she will not be able to visit the NICU if she does not comply with her infant’s care.
  4. D) Ask the father if the treatment plan is acceptable to him since he is a legal guardian as well.

Answer: B. Rationale: The nurse may empower or “enable” the client by supporting, guiding and creating a safe and comfortable environment wherein the client can effectively communicate or otherwise function (Pearson, 2015. p 2557).

18

All nurses agree to advocate for their patients. How would a nurse practice advocacy for the patient?

  1. Find the nursing supervisor in conflicting situations.
  2. Study and understand the law as it applies to the client's clinical condition.
  3. Assess the client's point of view and prepare to articulate this point of view.
  4. Make sure to document all the clinical changes in the medical record in a timely manner.

Correct answer: C. Rationale: Nurses strengthen their ability to advocate for a client when nurses identify personal values and then accurately identify the values of the client and articulate the client's point of view. (Pg. 2555)

19

You are participating in a clinical care conference for a patient with peptic ulcer disease. You talk with your colleagues about using the nursing code of ethics for nurses to guide care decisions for clients. A non-nursing colleague asks for you to explain the nursing code of ethics. Which of the following statements best describes this code?

  1. It has ways to improve the client’s ability to care for one’s self.
  2. It is a way to protect the patient's confidentiality.
  3. It ensures the same exact care to all patients.
  4. It defines the principles of right and wrong to provide patient care.

Correct answer: D. Rationale: Ethics refers to the standard of fright and wrong that influence human behavior, usually in terms of rights, obligations, benefits to society, fairness, or specific virtues. (pg. 2563)

20

According to Erikson, which stage of psychosocial development does the school age child (5-12 years) experience?

  1. industry v. inferiority
  2. trust v. mistrust
  3. autonomy v. shame
  4. intimacy v. isolation

Correct answer: A. Rationale- Erikson's 4th stage of development encompasses the basic virtue of competency. It is at this stage that the child’s peer group will gain greater significance and will become a major source of the child’s self-esteem. The child now feels the need to win approval by demonstrating specific competencies that are valued by society. If the child cannot develop the specific skill they feel society is demanding, then they may develop a sense of inferiority.

21

A nurse is caring for a patient with end-stage renal disease. The patient wants to go home and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patient's wishes with the family. The nurse is acting as the patient's:

  1. Educator
  2. Advocate
  3. Caregiver
  4. Case manager

Answer #2. Rationale: To be an advocate, the nurse must follow the patient’s wishes. The nurse shows advocacy by discussing the patient’s wishes with the family for better understanding and acceptance by the family.

22

A nurse discovers that a primary care provider has prescribed an unusually large dosage of a medication. Which is the most appropriate action?

  1. Administer the medication
  2. Notify the prescriber
  3. Call the pharmacist.
  4. Refuse to administer the medication.

Answer #2. Rationale: The nurse should call the person who wrote the order for clarification. Administering the medication is incorrect because knowing the dose is outside the normal range and not questioning it could lead to client harm and liability for the nurse.

23

A patient is terminally ill and is asking for more pain medication but the family refuses to let the nurse give him more pain medication. Which of the following should the nurse do next?

  1. Document the encounter and move on to the next patient.
  2. Talk to the family so that they might be reasonable.
  3. Give the pain medication to the patient.
  4. Call the physician and ask him/her to deal with the situation.

Answer #3 Rationale: In end-of-life care it is reasonable to give continuous pain medication.

24

A patient told his day nurse, who is conducting an ongoing physical assessment, that the night nurse did not attend his repeated calls. Which of the following interventions is the most appropriate initial action to be taken by the nurse as an advocate?
A. Discuss the complaint with the night nurse and clarify the incident.
B. Report the incidence directly and submit the documentation to the nursing manager.
C. Promise to provide all the care to the patient.
D. Observe the other nurse to determine if this negligence is repeated.

Answer A. Rationale: the nurse advocates for the patient and his/her rights. The first thing to be done is to clarify, scrutinize and discuss the complaint with the concerned nurse. If the issue is not resolved, it should be reported to the manager.

25

A nurse discovers that a primary care provider has prescribed an unusually large dosage of a medication. Which is the most appropriate action?

A. Administer the medication
B. Notify the prescriber
C. Call the pharmacist.
D. Refuse to administer the medication.

Answer B. Rationale The nurse should call the person who wrote the order for clarification. Administering the medication is incorrect because knowing the dose is outside the normal range and not questioning it could lead to client harm and liability for the nurse.

26

Nurses agree to be advocates for their patients. The practice of advocacy calls for the nurse to:
A. Seek out the nursing supervisor in conflicting situations
B. Work to understand the law as it applies to the client's clinical condition.
C. Assess the client's point of view and prepare to articulate this point of view.
D. Document all clinical changes in the medical record in a timely manner.

Answer C. Rationale: Nurses strengthen their ability to advocate for a client when nurses identify personal values and then accurately identify the values of the client and articulate the client's point of view.

27

Which statement would best explain the role of the nurse when planning care for a culturally diverse population?

  1. Include care that is culturally congruent with the staff from predetermined criteria.
  2. Focus only on the needs of the client, ignoring the nurse’s beliefs and practices.
  3. Blend the values of the nurse that are good for the client and minimize the client’s individual values and beliefs during care.
  4. Provide care while aware of one’s own bias, focusing on the client’s individual needs rather than the staff’s practices.

Answer: D. Rationale: Without understanding one’s own beliefs and values, a bias or preconceived belief by the nurse could create an unexpected conflict or an area of neglect in the plan of care for a client (who might be expecting something totally different from the care). During assessment, values, beliefs, and practices should be identified by the nurse and used as a guide to identify the choices by the nurse to meet specific needs/outcomes of that client. Therefore, identification of values, beliefs, and practices allows for planning meaningful and beneficial care specific for this client.

28

The nurse notes that an advance directive is in the client’s medical record. Which of the following statements represents the best description of guidelines a nurse would follow in this case?

  1. A durable power of attorney for health care is invoked only when the client has a terminal condition or is in a persistent vegetative state.
  2. A living will allows an appointed person to make health care decisions when the client is in an incapacitated state.
  3. A living will is invoked only when the client has a terminal condition or is in a persistent vegetative state.
  4. The client cannot make changes in the advance directive once the client is admitted into the hospital.

Answer: C. Rationale: A living will directs the client’s healthcare in the event of a terminal illness or condition. A durable power of attorney is invoked when the client is no longer able to make decisions on his or her own behalf. The client may change an advance directive at any time.

29

Ethical principles for professional nursing practice in a clinical setting are guided by the principles of conduct that are written as the:

  1. American Nurse’s Association Code of Ethics.
  2. Nurse Practice Act written by state legislation.
  3. Standards of care from experts in the practice field.
  4. Good Samaritan laws for civil guidelines.

Answer: A. Rationale: This set of ethical principles provides the professional guidelines established by the ANA to maintain the highest standards for ideal conduct in practice. As a profession, the ANA wanted to establish rules and then incorporate guidelines for accountability and responsibility of each nurse within the practice setting.

30

A client who had a "do not resuscitate" order passed away. After verifying there is no pulse or respirations, then nurse should next:

  1. Have family members say goodbye to the deceased.
  2. Call the transplant center.
  3. Remove all tubes and equipment (unless organ donation is to take place), clean the body, and position appropriately.
  4. Call the funeral director to come and get the body.

Answer: C, the body of the deceased should be prepared before the family comes in to view and say their goodbyes. This includes removing all equipment, tubes, supplies, and dirty linens according to protocol as well as bathing the client, applying clean sheets, and removing trash from the room.

31

A client's family member says to the nurse "The doctor said he will provide palliative care. What does that mean?" The nurse’s best response is:

  1. "Palliative care is given to those who have less than 6 months to live."
  2. "Palliative care aims to relieve or reduce the symptoms of a disease."
  3. "The goal of palliative care is to affect a cure if a serious illness or disease."
  4. "Palliative care means the client and family take a more passive role and the doctor focuses on the physiological needs of the client. The location of death will most likely occur in the hospital setting."

Answer: B, the goal of palliative care is the prevention, relief, reduction, or soothing of symptoms of disease or disorders without effecting a cure. Hospice care occurs for those who have less than 6 months to live

32

To be effective in meeting various ethnic needs, the nurse should:

  1. Treat all client alike.
  2. Be aware of client’s cultural differences.
  3. Act as if he or she is comfortable with the client's behavior.
  4. Avoid asking question about the client's cultural background.

Answer: B. All clients cannot be treated the same because they may have differences in cultures, religions, ethics, customs, etc. The nurse should ask questions about the client's cultural background to try and understand the client more and provide care that the client is comfortable with. The nurse should be aware of the client's cultural differences and should be respectful of them.

33

A woman in the early years of menopause asks the nurse what changes she can expect as she ages. Which of the following is not a common change for older adults?

  1. Vaginal lubrication decreases
  2. ‘Liver spots’- clusters of melanocytes are seen on the skin
  3. Increased blood glucose levels are common
  4. Fat is deposited in the abdominal and hip areas

ANSWER: C. Blood glucose may raise, but it is not common. Vaginal and skin changes are common. Fat is deposited in the abdomen and hip areas during the middle adult years (ages 40-65). Pages 1671-1673

34

The night shift nurse has just begun the shift. One of the patients is visibly upset, and informs the nurse that the prior nurse was rough when checking blood glucose levels and administering insulin injections, and repeatedly said for the patient to ‘Just be still. It’s only a prick’. What should the nurse do?

  1. Inform the patient that she will have time to recover by the morning.
  2. Ban the other nurse from participating in diabetic patient care.
  3. Report the situation to a supervisor.
  4. Apologize to the patient and administer the insulin injection.

ANSWER: C; a nurse who observes OR suspects ANY impairment in another professional is obligated to report it immediately to a supervisor. Page 2561

35

Which of the following are examples of nurses’ obligations in ethical decision making? Select All That Apply

  1. Work in accordance with own religious beliefs
  2. Carry out hospital policies
  3. Maximize client’s well-being
  4. Adhere to family’s wishes
  5. Balance client’s need for autonomy with family’s responsibilities

ANSWER: B/C/E Nurses and other medical personnel should approach each situation free of bias, including their own religious beliefs. Adherence to the family’s wishes is not a priority of care-the patient’s wishes should be respected, whether they have been verbalized or written-UNLESS power of attorney is involved. Box 44-4 on page 2569 gives more examples.

36

Which statement would best explain the role of the nurse when planning care for a culturally diverse population? The nurse will plan care to:

  1. Include care that is culturally congruent with the staff from predetermined criteria.
  2. Focus only on the needs of the client, ignoring the nurse’s beliefs and practices.
  3. Blend the values of the nurse that are for the good of the client and minimize the client’s individual values and beliefs during care.
  4. Provide care while aware of one’s own bias, focusing on the client’s individual needs rather than the staff’s practices.

Answer D. Rationale: Without understanding one’s own beliefs, the nurse may have difficulty or experience conflict when caring for a culturally diverse client. This can lead to moral and ethical conflicts in client care and therefore must be addressed.

37

A nurse learns that a patient who is paralyzed from the waist down and lives alone with no one to care for her is about to be released from the hospital. What is the best course of action for the nurse?

  1. Sign the patient up for a nursing home.
  2. Assume the patient will figure out a plan of care for themselves.
  3. Discuss options with the patient including home nurses, family who she may be able to live with, or moving into an assisted living facility.
  4. Tell the doctor the patient is not ready to leave the hospital because she is unstable.

Answer C. Rationale: This is the best way to approach the situation with this patient. Ignoring the issue is unethical and so is signing them up for care they did not consent for. Having the physician hold the patient is also wrong because the patient is not unstable and will not benefit from being held in the hospital.

38

A registered nurse (RN) is supervising an unlicensed assistive personnel (UAP). Which principle would the nurse follow when delegating tasks?

  1. a) The RN must directly supervise all delegated tasks.
  2. b) Follow-up with a delegated task is only necessary if the UAP is untrustworthy.
  3. c) After a task is delegated, it’s no longer the RN’s responsibility.
  4. d) The RN delegates a task based on the UAP’s skill set.

Correct answer D

39

The nurse is making team assignments and is assigning tasks to the unlicensed assistive personnel (UAP). What information should the nurse know before delegating tasks to the UAP?

  1. a) Whether the UAP has previously completed and practiced the delegated activities.
  2. b) All nursing activities performed by the UAP should be directly supervised by a registered nurse.
  3. c) Some nursing activities performed by the UAP should be directly supervised by a registered nurse.
  4. d) The UAP’s level of knowledge and comfort level in performing specific nursing activities should be considered.

Correct answer D.

40

An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction?

  1. a) elevating the foot of the bed to reduce edema
  2. b) providing passive range of motion exercises to the left extremities during the bed bath
  3. c) pulling up the client under the left shoulder when getting the client out of bed to a chair
  4. d) putting high top tennis shoes on the client after bathing

Correct answer C

41

The nurse is reviewing her yearly evaluations and sees her supervisor lists altruism as one of her strong assets as a nurse. Altruism can be defined as:

  1. “The concern of well being and welfare of others.”
  2. “Honesty and providing car according to code of ethics.”
  3. “Treats all patients fairly and equally.”
  4. All of the above

Answer: A Rationale: (Pearson, 2015, p 2564)

42

Barriers to coordinated care may include:

  1. Deficient patient knowledge.
  2. Limited access to resources.
  3. Non-adherence to the care plan.
  4. All of the above

Answer: D Rationale: (Pearson, 2015, p 2461)

43

Group members feel dissatisfied with their inflexible and impersonal leadership. The leader relies on rules and policies to direct the group’s efforts. Which leadership style best reflects this example?

  1. Shared leadership
  2. Laissez-faire leader
  3. Bureaucratic leader
  4. Situational leader

Answer: C Rationale: The bureaucratic leader does not trust him or herself to make decisions and instead relies on the organization's rules, policies, and procedures to direct the group's efforts. Group members usually feel dissatisfaction with the leader’s inflexibility and impersonal relations (Pearson, 2015, p 2490).

44

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)?

  1. A) A client requiring a colostomy irrigation.
  2. B) A client receiving continuous tube feedings.
  3. C) A client who requires urine specimen collections.
  4. D) A client with difficulty swallowing food and fluids.

Rationale: C, Assignment is based on skills of the staff member and needs of the client. The UAP is skilled in urine specimen collections and therefore this is the most appropriate assignment. Colostomy irrigations and tube feedings are considered invasive procedures and therefore should not be performed by UAPs. A client with difficulty swallowing food and fluids is at risk for aspiration and therefore is also inappropriate for UAP.

45

A nurse is completing discharge teaching for a client who is about to be discharged to home following a total hip replacement. The client asks the nurse why there is a case manager involved and expresses confusion about who is in charge. The client states, "I thought the doctor manages my care." Which is the best response by the nurse?

  1. A) "No, I manage your care."
  2. B) "You are correct; the doctor is responsible for managing your care."
  3. C) "A case manager coordinates everyone involved in your care to ensure your needs are met."
  4. D) "The case manager delegates your care to the nurse.”

Rationale: C, The case manager is responsible for assuring that all the client's healthcare needs are met in a cost-effective manner. The nurse may be a case manager; however, a staff nurse is not the most likely individual in the hospital setting to be the case manager. An agency usually has several case managers, who collaborate with nursing, the physician, and any other departments involved in the care of the client. A physician does not participate in care by being a case manager. Case managers coordinate disciplines of care for the client and do not delegate any care to other professionals.

46

Samantha the nurse manager has realized that one of her nurse’s is experiencing burnout. Which of the following is the best thing for her to do?

  1. Advise the nurse to take a long vacation.
  2. The nurse manager should ignore what she has observed it will be resolved without intervention.
  3. Remind the nurse of her loyalties to the hospital.
  4. Let the nurse verbalize her feelings and ask how she could help.

Answer D. Rationale: Reaching out and helping the staff is the most effective strategy in dealing with burn out. Knowing that someone is ready to help makes the staff feel important.

47

Samantha has been promoted as the new nurse manager. She wants to be an effective leader who exhibits dedication for serving her staff rather than being served. She wants to take the time to listen, prefers to be a teacher first before being a leader, which is a characteristic of?

  1. Transformational leader
  2. Charismatic leader
  3. Servant leader
  4. Transactional leader

Answer C. Rationale: Servant leaders are open-minded, listen deeply, try to fully understand others and not being judgmental.

48

According to Benner et al. (2010) the definition of professional behaviors is:

  1. effective nursing actions that form helping relationships based on technical knowledge and expertise.
  2. a process that facilitates the transformation of an individual from a lay person to a professional nurse.
  3. adherence to a strict moral or ethical code.
  4. any attempt to use one’s position or authority to shame, control, demean, humiliate, or denigrate another individual in order to gain emotional, psychological, or physical advantage over that individual.

Answer A. Rationale: The correct definition of professional behaviors is effective nursing actions that form helping relationships based on technical knowledge and expertise. Formation a process that facilitates the transformation of an individual from a lay person to a professional nurse. Integrity is adherence to a strict moral or ethical code. Abuse of power is any attempt to use one’s position or authority to shame, control, demean, humiliate, or denigrate another individual in order to gain emotional, psychological, or physical advantage over that individual (pg. 2480).

49

When delegating to other nurses, the delegator must use critical thinking and professional judgment and must follow the __________?

Answer: Five rights of delegation.

Rationale: The five rights of delegation include right task, right circumstance, right person, right direction, and right supervision. PG 2467

50

_________is the belief in the importance and moral worth of work.

Answer: Work Ethic

Rationale: A work ethic is defined as a belief in the importance and moral worth of work. Pg2491

51

_________is the means by which an interdisciplinary team works with a client to ensure that the client receives the care necessary to meet his needs across the healthcare continuum.

Answer: Care Coordination

Rationale: Care coordination is the means by which an interdisciplinary team works with a client to ensure that the client receives the care necessary to meet his needs across the healthcare continuum. PG 2460

52

A float nurse is assigned to a surgical unit. The nurse is receiving 2 clients from the post anesthesia care unit (PACU) at the same time. When delegating tasks to other PACU personnel who are not known to the nurse, which question would be most important to ask?

  1. A) Are you comfortable in performing the tasks being assigned?
  2. B) What is your highest educational level?
  3. C) How long have you worked on the floor?
  4. D) Who provided you the unit training?

Answer: A) Rationale: Since the float nurse is not familiar with staff, it is important to ask the worker if he/she is comfortable and had instruction in the task assigned. Principles of delegation state that the right task in the right situation by the right personnel is essential to client care. Asking the highest educational level, how long they worked on the floor, and who provided their training is not as important as if they are comfortable with performing the task.

53

The selection of a nursing care delivery system (NCDS) is critical to the success of client care in a nursing area. Which factor is essential to the evaluation of an NCDS?

  1. A) Identifying who will be responsible for making client care decisions.
  2. B) Determining how planned absences, such as vacations, will be scheduled so that all staff are treated fairly.
  3. C) Deciding what dress code will be implemented.
  4. D) Identifying salary ranges for various types of staff.

Answer: A) Rationale: Determining who has responsibility for making decisions regarding client care is an essential element of all client care delivery systems. Dress code, salary, and scheduling planned staff absences are important to any organizations, but they are not actually determined by the NCDS.

54

A client reports of a headache to an unregulated care provider (UCP). The UCP reports the client’s concerns to the nurse, who is busy with other clients. What is the best action by the nurse to address the client’s headache?

  1. A) Have the UCP inform another nurse that the client needs assistance.
  2. B) Delegate the UCP to administer acetaminophen.
  3. C) Ignore the UCP and continue with other clients.
  4. D) Ask UCP to do a thorough assessment of patient and determine best action.

Answer: A) Rationale: UCPs are not authorized to administer medication or perform assessments. However, they can enlist the help of another member of the team who is qualified to assist the client.

55

A nurse is caring for a patient with an order for placement of an indwelling urinary catheter. The nurse knows it is appropriate to delegate this task to which of the following personnel?

A – This task can be delegated to the certified nursing assistant (CNA).

B – This task can be delegated to the licensed practical nurse (LPN).

C – This task can be delegated to the unlicensed assistive personnel (UAP).

D – This task may only be performed by a registered nurse (RN).

Answer – B Rationale – Nurses often have a busy, task filled workload and require assistance to complete all patient care. The placement of an indwelling catheter is an invasive, sterile procedure, and must be done by an LPN or RN.

56

Which of the following must be done by an RN and not a nursing assistant? Select all that apply.

A – Admitting a patient from the post-anesthesia care unit

B – Ambulation post-op day 1

C – Ambulation post-op day 4

D – Normal skin care

E – Patient teaching

F – Suctioning

Answer – A, B, E, F

Rationale – An RN must admit the patient from the PACU. Ambulation post-op day 1 should be done by a licensed RN to ensure patient safety. Patient teaching is not within the scope of practice for a nursing assistant. Suctioning cannot normally be done by a nursing assistant; in some states, it may be allowed if they have had additional training, but in general, this is not within the scope of practice.

57

A nurse who is young unit manager is in charge of staff nurses who are senior to her, very articulate, confident, and sometimes aggressive. The nurse believes that she is the scapegoat of everything that goes wrong in her department. Which of the following is the best action for the nurse to take?

  1. Identify the source of conflict and understand the points of friction.
  2. Disregard what she feels and continue to work independently.
  3. Seek help from the Director of Nursing.
  4. Quit her job and look for other employment.

Answer: A Rationale: This involves a problem solving approach, which addresses the root cause of the problem.

58

Jenna is a nurse from the medical-surgical unit of a tertiary hospital. She was asked to float to the orthopedic floor, in which she has no prior experience working. Which client should be assigned to her?

  1. Client who had a total hip replacement two days ago and needs blood glucose monitoring.
  2. Client with a cast for a fractured femur and who has numbness and discoloration of the toes.
  3. A client with balanced skeletal traction and needs assistance with morning care.
  4. A client who had an above-the-knee amputation yesterday and has currently has a temperature of 101.4ºF.

Answer: A Rationale: A nurse from the medical-surgical floor floated to the orthopedic unit should be given clients with stable condition as those have care similar to her training and experience. A client who is in postoperative state is more likely to be on a stable condition.

59

The nurse is helping a nursing assistant who is giving a bed bath to a comatose patient who is incontinent. The nurse should intervene if she notices which of the following actions?

  1. The nursing assistant log rolls the patient to perform back care.
  2. The nursing assistant places an incontinence pad under the patient.
  3. The nursing assistant elevates the patient's head and rolls them onto their left side.
  4. The nursing assistant answers the phone with gloves on.

Answer: D Rationale: This puts other staff on the floor in danger when the nursing assistant contaminates the phone, and the behavior should be pointed out and stopped. The other options are appropriate actions that the nursing assistant is qualified to perform.

60

Which of the following is not a goal of functional nursing?

  1. Emphasize use of group collaboration
  2. One-to-one nurse patient ratio
  3. Provides continuous, coordinated and comprehensive nursing services
  4. Concentrates on tasks and activities

Answer B, Rationale: It is not realistic in most instances to try and have a one to one nurse to patient ratio. It is a goal for the healthcare group to collaborate amongst one another, to provide good care continuously, and to concentrate on tasks and activities.

61

Which task would you not delegate to a nurse’s assistant?

  1. Reposition patients every two hours.
  2. Taking patients vitals.
  3. Administer ordered Tylenol to patient.
  4. Give an immobile patient a bed bath.

Answer C. Rationale: Nurse’s assistant are not able administer medications; they are able to do all the other tasks listed.

62

A document that lists the medical treatment a person chooses to refuse if unable to make decisions is the:

  1. Durable power of attorney.
  2. Informed consent.
  3. Will.
  4. Advance directive.

Answer: D. Explanation: An advance directive is a written statement of a person's wishes regarding medical treatment, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor.

63

The RN knows that an example of a diagnostic error is:

  1. A failure to act on critical lab results reported.
  2. The failure of an IV pump to infuse at the programmed rate.
  3. Error in administering a PO medication.
  4. Error in calculating an IV drug dose.

Answer A. Explanation: While all the choices are errors, A is the answer because failure to act on critical lab values is the only diagnostic error.

64

The charge nurse is assigning patients to a floating nurse in the emergency room. Which of the following patients should be assigned to the floating nurse?
A) a patient who cannot sleep
B) a patient complaining of chest pain
C) a 20 year old with asthma who has audible wheezes
D) a patient with sudden shortness of breath and cyanosis

Answer: A Rationale: a patient who cannot sleep has the lowest priority and therefore should be assigned to a floating nurse

65

A charge nurse tells a new nurse, "You really need to get your skills up to speed." The statement hurts and embarrasses the new nurse. How can she best handle the situation?
A) Tell the charge nurse she feels hurt by her statement.
B) Ask for a private meeting to explore the charge nurse's concerns in detail.
C) Tell the charge nurse she needs to be more specific about what she means.
D) Discuss her feelings with a coworker in order to vent.

Answer B: The charge nurse's statement is vague and meeting privately with the charge nurse is one way to diffuse tension in a nonthreatening manner. This is best to gather information that might have professional value for the nurse.

66

At a staff meeting, a nurse manager shares that the unit is over budget by 2% and needs to reduce costs. A staff nurse suggests that report could be shortened so that nurses could finish their shifts on time. How should the nurse manager measure the success of this idea?

    1. Observe the change of shift report to determine how many nurses are leaving on time at the end of the shift.
    2. Delegate end-of-shift monitoring to the charge nurses
    3. Review the capital budget on a monthly basis
    4. Monitor for a reduction in hours per client day

Answer: 4 Rationale: Monitoring hours per client day will allow the nurse manager to determine if the staff members are reducing clinical hours by finishing closer to the end of their shift. A reduction in client hours per day may indicate that reducing the duration of end-of-shift report is effective.

67

A registered nurse on telemetry floor is preparing to discharge a patient. The patient has a 22 gauge IV on the left forearm that needs to be removed. While the preparing for the patient's discharge instructions, the registered nurse can delegate this task to which of the following?

  1. Charge nurse
  2. Unlicensed assistant personnel (UAP)
  3. The physician
  4. Licensed practical nurse (LPN)

Answer: D. Rationale: The registered nurse may delegate tasks to personnel who have been trained to perform the tasks like LPNs. The RN may ask the charge nurse to perform this task if they needed further assistance, but the RN should not delegate to the charge nurse. Nurses are not authorized to delegate tasks to physicians. The RN would not delegate a UAP to remove an IV because they do not have training to perform the task.

68

The charge nurse is going over the Rights of Delegation with a staff nurse. The charge nurse recognizes that further teaching is needed when the staff nurse names which of the following as a Right of Delegation?

  1. Right room
  2. Right task
  3. Right supervision
  4. Right direction

Answer: A. Right room Rationale: According to the ANA and the National Council of State Boards, The Rights of Delegation consist of: right task, right person, right direction, right circumstances, and right supervision.