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Applying Principles Associated with Delegation and Disaster Nursing

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									Safe and Effective Care/Disaster:
 Cultural Diversity, Ethical/Legal
 Delegation & Disaster Issues in
             Nursing

        Created by Professor Jill Ray
      Revised by Professor Brenda Rowe
    What tasks can an RN Delegate?

   Who is she delegating the task to?
   What type education/experience does that
    individual have?
   Is there something about the task that
    requires the skill/knowledge of an RN?
   Is there something about the task that
    requires the skill/knowledge of a
    specialized RN?
The person to whom the task is
   delegated must have the
 education and the experience
 required to complete the task
     safely and effectively.
When would a task be
considered routine…

when should a “routine”
task be completed by an
RN?
1. The nursing team consists of 2 RNs and 1 LPN.
The assignments would be considered appropriate
if the LPN were assigned to which of the following
                     patients?
A. A 3 year old who had an open reduction of a
   fractured radius performed yesterday.
B. A 5 year old who had a tonsillectomy
   yesterday.
C. A 7 year old who is being monitored for a
   seizure disorder.
D. A 2 year old who is receiving a tube feeding
   via a gastrostomy tube.
1. The nursing team consists of 2 RNs and 1 LPN.
The assignments would be considered appropriate
if the LPN were assigned to which of the following
                     patients?
A.   A 3 year old who had an open reduction of a fractured
     radius performed yesterday.
B.   A 5 year old who had a tonsillectomy yesterday.
C.   A 7 year old who is being monitored for a seizure
     disorder.
D. A 2 year old who is receiving a tube
     feeding via a gastrostomy tube.
     …Routine task…within her scope of
     practice.
     Tasks that can be delegated to an
                 LPN/LVN
   Any “regular” procedure that does not require
    assessment , teaching, or nursing judgment.
   The technical “doer”
   Physical care of clients with more complex
    conditions, selected treatments.
   Must be supervised by an RN.
   Saunders (2008) p.76…dressing changes,
    suctioning, urinary catheterization, medication
    administration (oral, sq, IM…)
 2. A client is admitted to room 703 with a
     diagnosis of acute GI bleed. Which of
    the following actions is BEST for the RN
                     to take?
A. Ask the UAP to obtain v/s while the RN obtains
   orders from the MD.
B. Ask the LPN to start an IV while the RN
   assesses breath sounds.
C. Ask the UAP to obtain equipment needed for
   the patient’s care while the RN assesses the
   patient.
D. Ask the LPN to assess the patient while the RN
   reviews orders with the MD.
     2.   A client is admitted to room 703 with a diagnosis of
             acute GI bleed. Which of the following actions is
                         BEST for the RN to take?

A.    Ask the UAP to obtain v/s while the RN obtains orders
      from the MD. Initial v/s
B.    Ask the LPN to start an IV while the RN assesses
      breath sounds. LPN can do aseptic
      technique…but IV is very invasive and
      this task would be hospital specific if OK.
C. Ask the UAP to obtain equipment
      needed for the patient’s care while
      the RN assesses the patient.
D.    Ask the LPN to assess the patient while the RN reviews
      orders with the MD. Assessment
What can be delegated to a nursing
       assistant or a UAP?
   Routine, unchanging procedures
   Assist with direct patient care activities
    under the supervision of an RN
   Scope of nursing practice is limited.
     How do we prioritize tasks?
   Maslow’s Hierarchy of Needs
   Basic needs must be met first
   Pain is considered a psychosocial need
   Deal with most acute   actual need
    first…
     3. The RN who is caring for clients in the
        oncology clinic, receives four phone
      messages. Which call should she return
                        first?
A. A client who is 5 days postop prostatectomy
   who complains of chills and a burning
   sensation with urination.
B. A client who is receiving chemotherapy who is
   experiencing fatigue.
C. A client newly diagnosed with colon cancer
   whose stool specimen tested positive for
   blood.
D. A client receiving chemotherapy for lung
   cancer who is experiencing a loss of appetite.
     3. The RN who is caring for clients in the
        oncology clinic, receives four phone
      messages. Which call should she return
                        first?

A. A client who is 5 days postop
      prostatectomy who complains of chills
      and a burning sensation with urination.
      …Most acute…
B.    A client who is receiving chemotherapy who is
      experiencing fatigue.
C.    A client newly diagnosed with colon cancer whose
      stool specimen tested positive for blood.
D.    A client receiving chemotherapy for lung cancer who is
      experiencing a loss of appetite.
4. A nurse from the oncology unit has been
 pulled to the pediatric unit. Which of the
  following patient assignments would be
             BEST for this RN?
A. A newborn newly admitted with fever of
   unknown origin.
B. A 10-year old who 4 days post operative
   appendectomy.
C. A 5-year old newly diagnosed with
   diabetes.
D. A 12-year old newly diagnosed with a
   seizure disorder.
4. A nurse from the oncology unit has been
 pulled to the pediatric unit. Which of the
  following patient assignments would be
             BEST for this RN?
A.   A newborn newly admitted with fever of
     unknown origin. …Ped. specialty…
B. A 10-year old who 4 days post
     operative appendectomy.
C.   A 5-year old newly diagnosed with diabetes.
     ..teaching…
D. A 12-year old newly diagnosed with a seizure
     disorder. ..teaching…
 5. The RN cares for patients on a medical-
surgical nursing unit. Which of the following
     patients should the RN see FIRST?
A. A 91-year old patient who is 72 hours postop
   colon resection who has a temperature of 100
   degrees F.
B. A 24-year old patient admitted to rule out
   ectopic pregnancy, whose BP is 90/58, HR
   101.
C. A 45-year old patient who was admitted 24
   hours ago with a diagnosis of r/o MI whose HR
   is 72, BP is 145/80.
D. A 50-year old male patient admitted with the
   diagnosis: “high blood pressure” who is
   complaining of back pain.
 5. The RN cares for patients on a medical-
surgical nursing unit. Which of the following
     patients should the RN see FIRST?
A.   A 91-year old patient who is 72 hours postop colon
     resection who has a temperature of 100 degrees F.
B. A 24-year old patient admitted to
     rule out ectopic pregnancy, whose
     BP is 90/58, HR 101….most acute…
C.   A 45-year old patient who was admitted 24 hours ago
     with a diagnosis of r/o MI whose HR is 72, BP is
     145/80.
D.   A 50-year old male patient admitted with the
     diagnosis: “high blood pressure” who is complaining of
     back pain.
  6.   An adult has been pre-medicated for her
 surgery. The operating room (OR) nurse, when
 going through the client’s chart, realizes that the
 consent form has not been signed. Which of the
following is the BEST action for the nurse to take?
A. Assume it is emergency surgery and the
   consent is implied.
B. Get the consent form and have the client
   sign it.
C. Tell the MD that the consent form is not
   signed.
D. Have a family member sign the consent
   form.
     6.An adult has been pre-medicated for her
 surgery. The operating room (OR) nurse, when
 going through the client’s chart, realizes that the
 consent form has not been signed. Which of the
following is the BEST action for the nurse to take?
A. Assume it is emergency surgery and the
   consent is implied.
B. Get the consent form and have the client sign
   it.
C. Tell the MD that the consent
     form is not signed.
D. Have a family member sign the consent form.
 7. Which of the following tasks could
       not be delegated to a UAP?
A. A patient with a fractured wrist who needs
   assistance completing her menu for the next
   day.
B. A patient with left-sided weakness who needs
   assistance to get out of bed to the bedside
   commode.
C. A preop patient who needs assistance learning
   to use the incentive Spiro meter.
D. A patient who is being started on Aldomet and
   needs his blood pressure checked every 4
   hours.
     7. Which of the following tasks could
          not be delegated to a UAP?
A.    A patient with a fractured wrist who needs assistance
      completing her menu for the next day.
B.    A patient with left-sided weakness who needs
      assistance to get out of bed to the bedside commode.
C. A preop patient who needs
      assistance learning to use the
      incentive Spiro meter….teaching…
D.    A patient who is being started on Aldomet and needs
      his blood pressure checked every 4 hours. …not the
      baseline BP – this is just routine
      monitoring…pts are started on Aldomet
      at the MD’s office and allowed to go
      home to monitor BP…
8. Which of the following clients should
        the nurse deal with first?
A. A client who needs her dressing
   changed.
B. A client who needs his endotracheal tube
   suctioned.
C. A client who needs to be medicated for
   postoperative pain.
D. A client who is incontinent and needs to
   be cleaned.
8. Which of the following clients should
          the nurse deal with first?
A.   A client who needs her dressing changed.
B. A client who needs his
     endotracheal tube
     suctioned….ABC’s…
C. A client who needs to be medicated for
   postoperative pain.
D. A client who is incontinent and needs to be
   cleaned.
9. Which of the following clients should
         the nurse observe first?
A. A client who has just returned from the
   OR
B. A client whose call light is not working
C. A client with Alzheimer’s disease
D. A client who is receiving a heating pad
   treatment.
9. Which of the following clients should
         the nurse observe first?

A. A client who has just
   returned from the OR…most
   acute, requires assessment…
B. A client whose call light is not working
C. A client with Alzheimer’s disease
D. A client who is receiving a heating pad
   treatment.
  10. Four clients have signaled with their
call bells for the nurse. Who should be seen
                      first?
A. A client who needs to use the toilet.
B. A client who does not have his glasses or
   hearing aid.
C. A client who has just been given
   morphine.
D. A client in a Geri chair with a restraint
   vest on.
  10. Four clients have signaled with their
call bells for the nurse. Who should be seen
                      first?
A. A client who needs to use the toilet.
B. A client who does not have his glasses or
   hearing aid.
C. A client who has just been
   given morphine… most acute
D. A client in a Geri chair with a restraint
   vest on.
 11. A nursing team consists of an RN, two
 LPNs, and an UAP. Which of the following
  patients should be assigned to the RN?
A. A 3 year old recovering from a gunshot wound
   to the abdomen that requires a dressing
   change.
B. A 1 year old who is receiving tube feedings via
   a nasogastric tube.
C. A 6 year old with cystic fibrosis who requires
   chest physiotherapy qid.
D. A 5 year who has been newly diagnosed with
   diabetes.
 11. A nursing team consists of an RN, two
 LPNs, and an UAP. Which of the following
  patients should be assigned to the RN?
A. A 3 year old recovering from a gunshot wound
   to the abdomen that requires a dressing
   change.
B. A 1 year old who is receiving tube feedings via
   a nasogastric tube.
C. A 6 year old with cystic fibrosis who requires
   chest physiotherapy qid.
D. A 5 year who has been newly
     diagnosed with diabetes.
     …teaching…
Don’t forget the basic principles of
              safety…
     12. The nurse enters the dayroom and
finds a fire. Which is the best initial action?

A. Evacuate any people in the room, beginning
   with the most ambulatory and ending with the
   least mobile.
B. Activate the fire alarm or call the operator,
   depending on the institution’s system.
C. Get a fire extinguisher and put out the fire.
D. Close all the windows and doors, and turn off
   any oxygen or electrical appliances.
     12. The nurse enters the dayroom and
finds a fire. Which is the best initial action?

A. Evacuate any people in the room,
     beginning with the most
     ambulatory and ending with the
     least mobile….Rescue, Activate,
     Confine, Extinguish …
B.   Activate the fire alarm or call the operator, depending
     on the institution’s system.
C.   Get a fire extinguisher and put out the fire.
D.   Close all the windows and doors, and turn off any
     oxygen or electrical appliances.
     13. The patient reports to you that he noticed
     that $20.00 was missing from his bedside table
       after the Respiratory Therapist finished his
        treatment. What action should you take?
A. Ask the Respiratory Therapist if he knows
   anything about the missing money.
B. Report the missing money to the head of the
   Respiratory Therapy department.
C. Report the missing money to your immediate
   supervisor.
D. Record the missing money in the nurses’ notes
   – the MD will follow up when he reads your
   note later in the day.
     13. The patient reports to you that he noticed
     that $20.00 was missing from his bedside table
       after the Respiratory Therapist finished his
        treatment. What action should you take?
A. Ask the Respiratory Therapist if he knows
   anything about the missing money.
B. Report the missing money to the head of the
   Respiratory Therapy department.
C. Report the missing money to
      your immediate supervisor…
      chain of command …
D. Record the missing money in the nurses’ notes
      – the MD will follow up when he reads your
      note later in the day.
           Chain of Command

   Always report to the RN in the scenario’s
    immediate supervisor.
     14.
       An adult has just arrived on the unit after
   surgery. Which of the following is the most
 appropriate task for the nurse to delegate to the
        certified nursing assistant (CNA)?

A. Assessment of the vital signs while the RN
   watches.
B. Suctioning the tracheotomy and reporting back
   to the nurse.
C. Changing the client’s postoperative dressing
   and then describing it to the RN.
D. Measure the amount of urine in the Urinary
   Drainage Bag.
     14.
       An adult has just arrived on the unit after
   surgery. Which of the following is the most
 appropriate task for the nurse to delegate to the
        certified nursing assistant (CNA)?

A. Assessment of the vital signs while the RN
   watches.
B. Suctioning the tracheotomy and reporting back
   to the nurse.
C. Changing the client’s postoperative dressing
   and then describing it to the RN.
D. Measure the amount of urine in
      the Urinary Drainage Bag.
15. The nurse is making the assignment for
the floor. There is one LPN and three RNs.
Which of the following clients should the LPN
          be assigned to care for?
A. A client who is intubated and a newly
   diagnosed diabetic.
B. A recent ICU transfer and a person with AIDS.
C. A client awaiting a nursing home bed and a
   client one day post-hernia repair.
D. A new admission for cholecystectomy and a
   client one day post-op mastectomy.
15. The nurse is making the assignment for
the floor. There is one LPN and three RNs.
Which of the following clients should the LPN
          be assigned to care for?
A. A client who is intubated and a newly
   diagnosed diabetic.
B. A recent ICU transfer and a person with AIDS.
C. A client awaiting a nursing
     home bed and a client one day
     post-hernia repair. … least acute…
D. A new admission for cholecystectomy and a
     client one day post-op mastectomy.
  16. The nurse is unfamiliar with a new
piece of OR equipment that is scheduled to
be used today. What is the best course of
                 action?
A. Ask another nurse for instructions on
   how to use it.
B. Wait until she has attended a class on
   using the equipment before using it.
C. Get another nurse who is familiar with
   the equipment to operate it.
D. Read the instructions provided with the
   equipment.
16. The nurse is unfamiliar with a new
    piece of OR equipment that is
    scheduled to be used today. What is
    the best course of action?
A.   Ask another nurse for instructions on how to use it.
B.   Wait until she has attended a class on using the
     equipment before using it… ideally…
C. Get another nurse who is familiar
     with the equipment to operate it.
D.   Read the instructions provided with the equipment.
•Confused
•Unsure of how
to do something
•Unsure of how
something works
   Never attempt a task you have not been
    trained to do
   Always follow manufacturer's guidelines
 17.   An adult has developed a stage II pressure
   ulcer. He is scheduled to receive wet to dry
dressings every shift. Which of the following team
  members would be the BEST choice to perform
                     this task?
A. An LPN who has worked on the nursing unit
   for 6 months.
B. A UAP who will graduate from a baccalaureate
   nursing program in 10 days.
C. A nursing assistant with 10 years experience
   on this nursing unit.
D. An LPN from the Surgical ICU who has been
   pulled to the nursing unit to help out today.
 17.   An adult has developed a stage II pressure
   ulcer. He is scheduled to receive wet to dry
dressings every shift. Which of the following team
  members would be the BEST choice to perform
                     this task?

A. An LPN who has worked on the
     nursing unit for 6 months.
B. A UAP who will graduate from a baccalaureate
   nursing program in 10 days.
C. A nursing assistant with 10 years experience
   on this nursing unit.
D. An LPN who has been pulled to the nursing
   unit to help out today.
18.    The nurse is about to administer the premedication
       prescribed for a woman scheduled for a lumpectomy. The
       client says, “I’ll be glad when the surgery is over. It will
       eliminate all the cancer from my body.” Which of the
       following is the BEST action for the nurse to take?

  A.    Medicate the client and tell the MD.
  B.    Correct the client’s misconceptions.
  C.    Call the MD without medicating the client.
  D.    Give the medications to the client and note her
        comment in the chart
18.     The nurse is about to administer the premedication
        prescribed for a woman scheduled for a lumpectomy. The
        client says, “I’ll be glad when the surgery is over. It will
        eliminate all the cancer from my body.” Which of the
        following is the BEST action for the nurse to take?

      A. Medicate the client and tell the MD.
      B. Correct the client’s misconceptions.
      C. Call the MD without
         medicating the client.
      D. Give the medications to the client and
         note her comment in the chart
19.    The nursing team, consisting of one RN, one
      LPN, and one nursing assistant has just
      received report from the previous shift. At
      the completion of the report, what action
      should the RN take FIRST?
A. Make assignments for the members of the
   nursing team.
B. Assess each patient that will be cared for by
   the nursing team.
C. Assess a patient who complains that the PCA
   has suddenly stopped controlling his postop
   pain.
D. Assess a patient who is requesting his
   prescribed prn for pain.
19.     The nursing team, consisting of one RN, one
       LPN, and one nursing assistant has just
       received report from the previous shift. At
       the completion of the report, what action
       should the RN take FIRST?
A.    Make assignments for the members of the nursing
      team.
B.    Assess each patient that will be cared for by the
      nursing team.
C. Assess a patient who complains that
      the PCA has suddenly stopped
      controlling his postop pain.
D.    Assess a patient who is requesting his prescribed prn
      for pain.
20. An RN who works in labor and delivery has been
 pulled to a medical nursing unit that specializes in
 diabetes to assist with patient care during the 7-3
  shift. Which of the following patient assignments
          would be appropriate for this RN?

A. A patient who is on an insulin drip.
B. A patient with a new diagnosis of
   diabetes.
C. A patient who has received an insulin
   pump and is being prepared for
   discharge.
D. A patient who is being treated for high
   blood pressure.
20. An RN who works in labor and delivery has been
 pulled to a medical nursing unit that specializes in
 diabetes to assist with patient care during the 7-3
  shift. Which of the following patient assignments
          would be appropriate for this RN?

A. A patient who is on an insulin drip.
B. A patient with a new diagnosis of diabetes.
C. A patient who has received an insulin pump
   and is being prepared for discharge.
D. A patient who is being treated
     for high blood pressure.
21. The nurse evaluates assignments on a
medical/surgical unit. The assignments are
 deemed appropriate if a nursing assistant
  performs which of the following tasks?
A. Admission vital signs for a patient who is
   scheduled for surgery tomorrow.
B. Before lunch accucheck for a patient who
   is receiving hyperalimentation fluids.
C. A dressing change for a client with a
   pressure ulcer.
D. Discharge teaching for a client diagnosed
   with COPD.
 21. The nurse evaluates assignments on a
medical/surgical unit. The assignments are
deemed appropriate if a nursing assistant
  performs which of the following tasks?
A.   Admission vital signs for a patient who is
     scheduled for surgery tomorrow.
B. Before lunch accucheck for a
     patient who is receiving
     hyperalimentation fluids…not a
     new HAF administration…
C. A dressing change for a client with a pressure
   ulcer.
D. Discharge teaching for a client diagnosed with
   COPD.
 22. The nursing team consists of one RN,
one LPN, and one nursing assistant. Which
  of the following patients should the RN
              attend to FIRST?
A. A patient who is experiencing dysuria after a
   cystoscope.
B. A patient whose BP has changed from 160/82
   to 92/75.
C. A patient who is experiencing incisional pain 24
   hours postop cholecystectomy.
D. A patient who is visually impaired who needs
   assistance to get OOB to the bedside
   commode.
 22. The nursing team consists of one RN,
one LPN, and one nursing assistant. Which
  of the following patients should the RN
              attend to FIRST?
A.   A patient who is experiencing dysuria after a
     cystoscope.
B. A patient whose BP has
     changed from 160/82 to 92/75.
C. A patient who is experiencing incisional pain 24
   hours postop cholecystectomy.
D. A patient who is visually impaired who needs
   assistance to get OOB to the bedside
   commode.
 23. Mr. Smith in RM 412 has a living will.
 The RN should consult this document prior
   to the implementation of which of the
            following MD orders?
A. Turn, cough, deep breath q 2hours while
   awake.
B. Osmolite 500ml QID via PEG tube.
C. OOB QID to bedside chair.
D. Active ROM exercises QID.
 23. Mr. Smith in RM 412 has a living will.
 The RN should consult this document prior
   to the implementation of which of the
            following MD orders?
A. Turn, cough, deep breath q 2hours while
   awake.
B. Osmolite 500ml QID via PEG
   tube. …life sustaining tx…
C. OOB QID to bedside chair.
D. Active ROM exercises QID.
24. Which phone call should the RN
           return first?
A. A patient who is 5 days postop hysterectomy
   who is complaining of severe abdominal pain.
B. A patient receiving chemotherapy who is
   complaining of discomfort secondary to oral
   lesions.
C. A patient 2 days postop Laparoscopic
   Cholecystectomy who is complaining of
   abdominal distention.
D. A dialysis patient who complains of dry, itchy
   skin.
24. Which phone call should the RN
           return first?
A. A patient who is 5 days postop
     hysterectomy who is complaining of
     severe abdominal pain.
B.   A patient receiving chemotherapy who is complaining
     of discomfort secondary to oral lesions.
C.   A patient 2 days postop Laparoscopic Cholecystectomy
     who is complaining of abdominal distention.
D.   A dialysis patient who complains of dry, itchy skin.
25.   The nurse instructs the nursing assistant to assist her
      in obtaining output measurements for a patient
      receiving Lasix. There would be cause for concern if
      the instructions given to the nursing student included
      which of the following:
A. Empty the urinary drainage bag into the
   measuring device kept in the patient’s
   bathroom.
B. Palpate the patient’s abdomen to determine if
   his bladder is empty.
C. Milk the urine in the drainage tubing into the
   urinary drainage bag prior to emptying the
   bag.
D. Report back to me with a description of the
   color and amount of urine
25. The nurse instructs the nursing assistant to assist
    her in obtaining output measurements for a
    patient receiving Lasix. There would be cause for
    concern if the instructions given to the nursing
    student included which of the following:
  A.   Empty the urinary drainage bag into the measuring
       device kept in the patient’s bathroom.
  B. Palpate the patient’s abdomen to
       determine if his bladder is empty.
  C.   Milk the urine in the drainage tubing into the urinary
       drainage bag prior to emptying the bag.
  D.   Report back to me with a description of the color and
       amount of urine
 26. A male UAP complains to the RN that
 another RN on the unit often slaps him on
 the buttocks. What action should the RN
                  take?
A. Report the complaint to her immediate
   supervisor.
B. Discuss the complaint with the other RN.
C. Ensure that in the future that assignments are
   made in such a way that these two individuals
   will not be working with each other.
D. Complete an incident report about this
   complaint.
26. A male UAP complains to the RN that
    another RN on the unit often slaps him
    on the buttocks. What action should
    the RN take?
A. Report the complaint to her
     immediate supervisor.
B. Discuss the complaint with the other RN.
C. Ensure that in the future that assignments are
   made in such a way that these two individuals
   will not be working with each other.
D. Complete an incident report about this
   complaint.
27. An RN from the ICU is pulled to the
    oncology unit. Which assignment is
    most appropriate for this RN to take?
A. A 45-year old after a colon resection.
B. A 92-year old comatose patient in the
   terminal stages of gastric cancer.
C. A 21-year old receiving 5FU IV.
D. A 65-year old with a positive prostate
   biopsy.
27. An RN from the ICU is pulled to the
    oncology unit. Which assignment is
    most appropriate for this RN to take?
A. A 45-year old after a colon
   resection.
B. A 92-year old comatose patient in the
   terminal stages of gastric cancer.
C. A 21-year old receiving 5FU IV.
D. A 65-year old with a positive prostate
   biopsy.
28. A bomb has just exploded at a local
    school. What would be the MOST
    appropriate action for an RN with 20
    years experience on a medical-surgical
    nursing unit to take?
A. Drive immediately to the site of the disaster
   and begin working with victims inside the
   building.
B. Contact all the RNs she knows who live within
   5 miles of the school to encourage them to go
   to the site and begin assisting victims.
C. Contact the closest hospital to the disaster and
   volunteer her services.
D. Drive immediately to the school to assist
   distraught parents.
28. A bomb has just exploded at a local
    school. What would be the MOST
    appropriate action for an RN with 20
    years experience on a medical-surgical
    nursing unit to take?
A.   Drive immediately to the site of the disaster and begin
     working with victims inside the building.
B.   Contact all the RNs she knows who live within 5 miles
     of the school to encourage them to go to the site and
     begin assisting victims.
C. Contact the closest hospital to the
     disaster and volunteer her services.
D.   Drive immediately to the school to assist distraught
     parents.
What is meant by the term
         Triage?
29. The following represents the categories
  that can be used to assist with triage of
disaster victims. Which category would be
                 seen first?

A. Yellow
B. Green
C. Red
D. Black
29. The following represents the categories
    that can be used to assist with triage of
    disaster victims. Which category would
    be seen first?

A. Yellow
B. Green

C. Red
D. Black
Red: Immediate Care. Class I. Critical, life
  threatening. Compromised airway, shock,
  hemorrhage
Yellow: Minimal Care. Urgent. Class II. Major
  illness or injury. Requires treatment within 20
  minutes to 2 hours. Open fracture. Chest
  wound.
Green: Delayed Care. Class III. Care may be
  delayed 2 hours or more. Minor injuries;
  walking wounded, closed fracture, sprain, strain.
Black: Expectant Care. Class IV. Dead or
  expected to die. Massive head injury. Extensive
  full-thickness burns.
     30. The RN at the Home Nursing agency
receives messages from four of her patients.
  Which patient should she contact FIRST?
A. 45 year old patient with Bronchitis who has
   been experiencing vomiting and diarrhea for
   24 hours.
B. 51 year old patient with Diabetes whose AM
   blood sugar was 175.
C. 49 year old patient with peripheral vascular
   disease who complains of “cold feet”.
D. 55 year old patient with essential hypertension
   who experiences “light-headedness” when he
   stands up.
     30. The RN at the Home Nursing agency
receives messages from four of her patients.
  Which patient should she contact FIRST?
A. 45 year old patient with
      Bronchitis who has been
      experiencing vomiting and
      diarrhea for 24 hours.
B. 51 year old patient with Diabetes whose AM
   blood sugar was 175.
C. 49 year old patient with peripheral vascular
   disease who complains of “cold feet”.
D. 55 year old patient with essential hypertension
   who experiences “light-headedness” when he
   stands up.
31.        The RN in an Emergency Department has been asked to
           use the California Fire Chiefs Association Victim triage tag
           system. Which of the following individuals would be
           classified in the “Green” category (care may be delayed 2
           hours or more):
      A. A patient who is conscious and has sustained
         an opened fracture of the femur.
      B. A patient who is conscious and does not
         appear to have any injuries of any type.
      C. A patient who is conscious and has sustained
         multiple scrapes and bruising of the face and
         upper body.
      D. A patient who is unconscious and has an open
         skull fracture.
31. The RN in an Emergency Department has been
    asked to use the California Fire Chiefs Association
    Victim triage tag system. Which of the following
    individuals would be classified in the “Green”
    category (care may be delayed 2 hours or more): :
  A.   A patient who is conscious and has sustained an opened fracture
       of the femur. …Yellow (treatment within 2 hrs to 20
       minutes)
  B.   A patient who is conscious and does not appear to have any
       injuries of any type.
  C.   A patient who is conscious and has sustained
       multiple scrapes and bruising of the face and
       upper body.
  D.   A patient who is unconscious and has an open skull fracture.
       …red (immediate care to save life/ critical care)
       black (if severe head injury …expectant care
       only)
32. The patient the RN is assessing at the
scene of a disaster has full thickness burns
 that cover 90 percent of his body. What
     classification would he be given?
 A. Red
 B. Yellow
 C. Green
 D. Black
32. The patient the RN is assessing at the
scene of a disaster has full thickness burns
 that cover 90 percent of his body. What
     classification would he be given?
 A. Red (critical care intervention immediately)
 B. Yellow (20 minutes to 2 hours)
 C. Green (needs to be seen but care can be
    delayed for 2 hours or more without
    significantly impacting pt outcomes)
 D. Black (death
    anticipated…expectant care)
     33. After receiving report from the 11-7
     shift nurse, which of the following should
                 the nurse see first?
A. A 40-year old client who had gastric bypass
   surgery yesterday.
B. A 21 year-old who has suddenly developed
   wheezes.
C. A 75 year old client with left-sided weakness
   who is requesting assistance to the bedside
   commode.
D. A 32-year old who is refusing her morning
   dose of Lasix.
     33. After receiving report from the 11-7
     shift nurse, which of the following should
                 the nurse see first?
A.    A 40-year old client who had gastric bypass
      surgery yesterday.
B. A 21 year-old who has suddenly
      developed wheezes.
C. A 75 year old client with left-sided weakness
   who is requesting assistance to the bedside
   commode.
D. A 32-year old who is refusing her morning
   dose of Lasix.
Chemical Incidents
34.        Triage in the field for chemical incidents are divided into the “Hot
           Zone”, “Warm Zone”, and the “Cold Zone”. An individual who is
           considered contaminated, but is a Code Red (requires immediate
           intervention to survive) would be taken to which area first?

      A. A code red patient is taken immediately to the hospital.
         The EMT’s perform chemical decontamination on this
         individual en route to the hospital.
      B. All patients are taken to the “Hot Zone” first for
         minimal triage and medical care. Triage is done in this
         area to determine expectant status.
      C. This patient would proceed directly to the Cold Zone for
         treatment and would skip the decontamination process.
      D. A code red patient would not be removed from the
         contaminated area as his chances of survival are poor.
34. Triage in the field for chemical incidents are divided
    into the “Hot Zone”, “Warm Zone”, and the “Cold
    Zone”. An individual who is considered
    contaminated, but is a Code Red would be taken to
    which area first?
  A.   A code red patient is taken immediately to the hospital.
       The EMT’s perform chemical decontamination on this
       individual en route to the hospital.
  B. All patients are taken to the “Hot
       Zone” first for minimal triage and
       medical care. Triage is done in this
       area to determine expectant status.
  C. This patient would proceed directly to the Cold Zone for
     treatment and would skip the decontamination process.
  D. A code red patient would not be removed from the
     contaminated area as his chances of survival are poor.
In the Field:

Hot Zone: area immediately
 adjacent to the location of
 the incident. Minimal
 triage/medical care –
 limited to airway and
 hemorrhage control,
 administration of antidotes,
 and identification of
 expectant cases.
            In the Field….

Warm Zone: a distance of at least 300 feet
 from the outer perimeter of the hot zone.
 Upwind, uphill from the contaminated
 area. Rapid triage to determine expectant
 status. Minimal treatment. Priority is to
 decontaminate.
           In the Field….

Cold Zone: Area adjacent (uphill and
 upwind) from warm zone.
 Decontaminated victims seen. Thorough
 triage. Victims directed for treatment.
  35. Staff in the field must wear
    protective gear in which of the
            following areas:
A. Hot Zone only.
B. Warm Zone only.
C. Hot and warm zones, required in cold
   zone if unable to secure a location for
   this zone which is uphill and upwind.
D. Hot, Warm, and Cold Zone.
  35. Staff in the field must wear
    protective gear in which of the
            following areas:
A. Hot Zone only.
B. Warm Zone only.
C. Hot and warm zones, required in cold
   zone if unable to secure a location for
   this zone which is uphill and upwind.
D. Hot, Warm, and Cold Zone.
     36. Which of the following patients could
      enter the area designated as the “cold
                      zone”?
A.    A Code Yellow patient who not gone through
      the decontamination process.

B.    A Code Green patient who is ambulatory and
      has not gone through the decontamination
      process.

C.    A Code Red patient who is deemed too critical
      to go through the decontamination process.

D. A Code Red patient who has gone through
      litter decontamination in the Warm Zone.
     36. Which of the following patients could
      enter the area designated as the “cold
                      zone”?
A.    A Code Yellow patient who not gone through the
      decontamination process.
      …all must go through decontamination…
B.    A Code Green patient who is ambulatory and has not
      gone through the decontamination process.
      all must go through decontamination…
C.    A Code Red patient who is deemed too critical to go
      through the decontamination process.

D. A Code Red patient who has gone
      through litter decontamination in
      the Warm Zone.
37. A train near the city’s high school has derailed and
     has spilled radioactive material onto the roadways.
     The school nurse should communicate which of the
     following statements to the parents of the
     students?
  A. The buses will not run this afternoon. Parents
      must arrange for alternate transportation home
      for their children.
  B. Parents are required to give verbal permission
      (over the phone) for their child to drive their
      vehicle home under these conditions.
  C. The students will be kept at the High School
      until the local authorities declare the area as
      being “all clear”.
  D. The students will be allowed to walk home as
      long as they avoid the contaminated area.
37. A train near the city’s high school has derailed and
    has spilled radioactive material onto the roadways.
    The school nurse should communicate which of the
    following statements to the parents of the
    students?
  A. The buses will not run this afternoon. Parents must
     arrange for alternate transportation home for their
     children.
  B. Parents are required to give verbal permission (over
     the phone) for their child to drive their vehicle home
     under these conditions.
  C. The students will be kept at the
       High School until the local
       authorities declare the area as being
       “all clear”.
  D. The students will be allowed to walk home as long as
       they avoid the contaminated area.
38. A triage nurse working in the Warm Zone at a
    hospital’s emergency room receives a patient
    transported by ambulance from the site of a
    chemical spill. What action should she take first?

  A. Admit the patient to the main section of
     the hospital’s emergency room.
  B. Determine the decontamination that
     occurred in the field.
  C. Assess the patient.
  D. Administer oxygen via nasal cannula.
38. A triage nurse working in the Warm Zone at a
    hospital’s emergency room receives a patient
    transported by ambulance from the site of a
    chemical spill. What action should she take first?

  A. Admit the patient to the main section of
      the hospital’s emergency room.
  B. Determine the
      decontamination that
      occurred in the field.
  C. Assess the patient.
  D. Administer oxygen via nasal cannula.
39. An 80-year old client recovering from a
    CVA is being transferred to a skilled
    nursing facility. The nurse should assign
    this client to which of the following staff
    members?
A. A UAP who is about to graduate from a
   baccalaureate nursing program.
B. A certified nursing assistant with 10 years
   experience.
C. A new graduate who passed the NCLEX last
   week.
D. An LPN with 25 years experience at this
   facility.
39. An 80-year old client recovering from a
    CVA is being transferred to a skilled
    nursing facility. The nurse should assign
    this client to which of the following staff
    members?
A. A UAP who is about to graduate from a
   baccalaureate nursing program.
B. A certified nursing assistant with 10 years
   experience.
C. A new graduate who passed the
     NCLEX last week.
D. An LPN with 25 years experience at this
     facility.
40. A patient tells you that he suspects that
    a nursing assistant has stolen his
    watch. What action should you take?

A. Report the accusation to the hospital’s public
   relations department.
B. Watch the nursing assistant to see if she’s
   wearing the watch.
C. Listen outside the break room door to the
   nursing assistant’s conversation with her
   friends to see if she incriminates herself.
D. Report the accusation to your immediate
   supervisor.
40. A patient tells you that he suspects that
    a nursing assistant has stolen his
    watch. What action should you take?

A. Report the accusation to the hospital’s public
   relations department.
B. Watch the nursing assistant to see if she’s
   wearing the watch.
C. Listen outside the break room door to the
   nursing assistant’s conversation with her
   friends to see if she incriminates herself.
D. Report the accusation to your
     immediate supervisor.
41. A man is prepared for discharge during the
    7-3 shift. He was admitted for treatment of
    AIDS and Candida esophagitis. Who should
    be assigned to care for this patient?
  A. The LPN who has worked on this unit for 10
     years.
  B. The nursing assistant who has just completed
     an in-service on the special needs of AIDS
     patients.
  C. The RN who has 3 years experience on this
     nursing unit.
  D. The RN who was pulled to this unit from the
     Cardiac ICU.
41. A man is prepared for discharge during the
    7-3 shift. He was admitted for treatment of
    AIDS and Candida esophagitis. Who should
    be assigned to care for this patient?
  A. The LPN who has worked on this unit for 10
     years.
  B. The nursing assistant who has just completed
     an in-service on the special needs of AIDS
     patients.
  C. The RN who has 3 years
       experience on this nursing unit.
  D. The RN who was pulled to this unit from the
       Cardiac ICU.
42. Which area described below would be
    most ideal to serve as the “Cold Zone”
    in the Field after a chemical incident?
A. The parking lot immediately beside the roadway
   where a truck carrying a chemical toxin has
   crashed.
B. The gym that is located 100 feet from the
   location of the crash of a truck carrying a
   chemical toxin, and is uphill and upwind of the
   chemical incident.
C. The main building of an elementary school,
   located over 300 feet from the outer perimeter
   of the “Hot Zone”, and is uphill and upwind of
   the chemical incident.
D. The hospital emergency room.
42. Which area described below would be
    most ideal to serve as the “Cold Zone”
    in the Field after a chemical incident?
A. The parking lot immediately beside the roadway where
   a truck carrying a chemical toxin has crashed.
B. The gym that is located 100 feet from the location of
   the crash of a truck carrying a chemical toxin, and is
   uphill and upwind of the chemical incident.
C. The main building of an elementary
   school, located over 300 feet from
   the outer perimeter of the “Hot
   Zone”, and is uphill and upwind of
   the chemical incident.
D. The hospital emergency room.
  In summary

Delegation:
•Teaching
•Assessment
•Specialized skills
                Prioritization

   Most acute basic need
   Eliminate expected/usual
   Pain is the answer ONLY if there is a
    sudden increase or it is unusual pain
                    Triage

   Red seen first…most acutely ill with best
    chance of survival.
   In disaster select the answer that will do
    the most good for the most people as
    your first course of action
             African American

   Head nodding does not always mean
    agreement.
   Time orientation varies according to age,
    socioeconomic subgroup
   Elderly respected, large extended family is
    important
   Religion source of strength
             Asian American
   Silence valued
   Eye contact may be considered
    inappropriate
   Head nodding does not always mean
    agreement
   Usually will not touch others during
    conversation
   Head is considered sacred
    European (white) origin American

   Silence can be respectful or disrespectful
   Time is valued
   Man is dominant figure
   Tendency to be stoical when expressing
    physical concern
           Hispanic American

   Avoiding eye contact with authority person
    indicates respect
   Dramatic body language is used to
    express emotions or pain
   May place more value on relationship and
    events than being on time
   Extended family is highly regarded
              Native America

   Silence shows respect
   Eye contact is viewed as disrespectful
   Personal space is important
   Elders are honored
43. The nurse is providing care to a Cuban American client
who is terminally ill. Numerous family members are present
most of the time, and many of the family member are
emotional. What is the most appropriate action?

1.   Restrict the number of family members visiting
     at one time.
2.   Inform the family that emotional outburst are
     to be avoided.
3.   Request permission to move the client to a
     private room and allow the family to visit.
4.   Contact the physician to speak to the family
     regarding their behaviors.
43. The nurse is providing care to a Cuban American client
who is terminally ill. Numerous family members are present
most of the time, and many of the family member are
emotional. What is the most appropriate action?
1.   Restrict the number of family members visiting
     at one time.
2.   Inform the family that emotional outburst are
     to be avoided.
3.   Request permission to move the
     client to a private room and allow
     the family to visit.
4.   Contact the physician to speak to the family
     regarding their behaviors.
44. The nurse is planning to instruct the Mexican American
client about nutrition and dietary restrictions. What should
the nurse be aware of in developing a plan for this ethnic
group.

1.   Enjoys food that lacks color, flavor, and
     texture.
2.   Primarily eats raw fish.
3.   Enjoys eating red meat.
4.   Views food as a primary form of
     socialization.
44. The nurse is planning to instruct the Mexican American
client about nutrition and dietary restrictions. What should
the nurse be aware of in developing a plan for this ethnic
group.

1.   Enjoys food that lacks color, flavor, and
     texture.
2.   Primarily eats raw fish.
3.   Enjoys eating red meat.
4.   Views food as a primary
     form of socialization.
45. Which of the following interventions is unlikely to
facilitate effective communication between the dying client
and his or her family?

1.   The nurse encourages the client and family to
     identify and discuss feelings openly.
2.   The nurse makes decisions for the client and
     family to relieve them of unnecessary
     demands.
3.   The nurse assists the client and family in
     carrying out spiritually meaningful practices.
4.   The nurse maintains a calm attitude and one
     of acceptance when the family or client
     expresses anger.
45. Which of the following interventions is unlikely to
facilitate effective communication between the dying client
and his or her family?

1.   The nurse encourages the client and family to
     identify and discuss feelings openly.
2.   The nurse makes decisions for
     the client and family to relieve
     them of unnecessary demands.
3.   The nurse assists the client and family in
     carrying out spiritually meaningful practices.
4.   The nurse maintains a calm attitude and one
     of acceptance when the family or client
     expresses anger.
46. Which of the following allows a client to provide
instructions to the physician regarding end of life decisions?


1.   Living Will
2.   Durable Power of Attorney for Healthcare
3.   Substituted Decision affidavit
4.   Do Not Resuscitate Order
46. Which of the following allows a client to provide
instructions to the physician regarding end of life decisions?


1.   Living Will
2.   Durable Power of Attorney for Healthcare
3.   Substituted Decision affidavit
4.   Do Not Resuscitate Order
47. Which of the following statements about informed
consent represents a need for an intervention by the nurse.
Select all that apply

1.   “I agree to surgery but now what is
     going to be done.”
2.   “Whatever needs to be done just do it.”
3.   “I consent to the surgery in spite of the
     risks.”
4.   “My wife insists I have this surgery.”
5.   “This was a difficult decision but I had
     the information to make the decision.”
47. Which of the following statements about informed
consent represents a need for an intervention by the nurse.
Select all that apply

1.   “I agree to surgery but now what is
     going to be done.”
2.   “Whatever needs to be done just do
     it.”
3.   “I consent to the surgery in spite of the risks.”
4.   “My wife insists I have this
     surgery.”
5.   “This was a difficult decision but I had the information
     to make the decision.”
48. The client has agreed to participate in a double-blind
study. Which statement indicates that the client does not
understand the study risks?

1.   “I can quit the study at any time.”
2.   “ My personal health information will be
     protected during the study.”
3.   “The consent form identified the risks of the
     study.”
4.   “The researcher will tell be what medication I
     am receiving.”
48. The client has agreed to participate in a double-blind
study. Which statement indicates that the client does not
understand the study risks?

1.   “I can quit the study at any time.”
2.   “ My personal health information will be
     protected during the study.”
3.   “The consent form identified the risks of the
     study.”
4.   “The researcher will tell be
     what medication I am
     receiving.”

								
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