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Study guide for Nurses. Pls. don't reproduce. Property of NCSBN and other rightful owner.
NCSBN REVIEW FOR NCLEX I. Delegation A. Definition: A process by which responsibility and authority for performing tasks are transferred from one individual to another who accepts that authority and responsibility. B. Delegation involves 1. Responsibility: an obligation to accomplish a task 2. Accountability: accepting ownership for the results or lack of 3. Authority: right to act or empower C. Principles of Delegation 1. You can only delegate those tasks for which you are responsible 2. The delegator remains accountable for the task 3. Along with responsibility for a task, you must also transfer the authority necessary to complete the task 4. Know well the task to be delegated 5. Delegation is a contractual agreement that is entered into voluntarily 6. Match the task to the individual Scope of Practice of Nursing Personnel I. Registered Nurses: A. Baccalaureate prepared nurses are equipped to care for individuals, families, groups and communities in both structured and unstructured health settings B. Associate degree prepared nurses are equipped to care for individuals in a structured health care environment C. RNs cannot delegate: 1. Initial assessment of patients 2. Evaluation of patient data 3. Nursing judgment 4. Patient/family education/evaluation 5. Nursing diagnosis/nursing care planning II. Licensed practical or vocational nurses are equipped to assist in implementing a defined plan of care and to perform procedures according to protocol. Assessment skills are directed at differentiating normal from abnormal. Competence is in caring for physiologically stable patients with predictable conditions. III. Unlicensed assistive personnel have the most limited scope of practice. They can assist in a variety of direct patient care activities such as bathing, transferring, ambulating, feeding, toileting, obtaining measurements such as vital signs, height, weight and intake and output. They can also perform indirect activities such as housekeeping, transporting and stocking supplies. D. Steps to Delegation 1. Define the task 2. Determine the delegate a. Is the task within the scope of practice of the delegate? b. Scope of practice is defined i. Nurse Practice Acts: each state defines what nurses may do ii. Standards of Practice: the American Nurses Association and specialty nursing organizations define standards of nursing practice iii. Organizational policies and job descriptions c. Does the ability of this caregiver match the needs of the task? 3. Communicate clearly about expectations regarding the task a. State clearly who will do what by when and how, where and why it will be done b. State clearly the outcomes you expect 4. Reach mutual agreement about the task to be completed a. Validate with the delegate that he/she understands what is to be done and the outcomes that are expected b. Discuss possible foreseeable problems and potential solutions 5. Monitor the task and provide guidance as needed a. Was the task completed according to specifications? 6. Evaluate results a. Was the desired outcome obtained? 7. Provide feedback to individual on his/her performance a. Review with the delegate what went right as well as what went wrong with the process Joint Commission on Health Care Organization Criteria for Making Assignments [From NC.2.1.2] Assigning responsibility to nursing staff members for providing nursing care to patients is based on consideration of the following seven elements: 1. Complexity of patient care: How involved is the care that is required? 2. Dynamics of the patient's status: How often is the patient's condition changing? 3. Complexity of the assessment: What is required to completely assess the patient's condition? 4. Technology involved: Is the patient being monitored for complex or life threatening problems? Or is complex technology involved? 5. Degree of supervision: What level of supervision is required by the nursing personnel based on their skill and competence? 6. Availability of supervision: Is the appropriate nursing supervision available to provide the degree of supervision determined in number 5? 7. Infection control and safety precautions: To what degree are universal precautions enforced. Are staff competent to carry out emergency, infection control and safety procedures? II. Quality Improvement A. Quality Definition: The degree to which patient care services increase the probability of desired outcomes and reduce the probability of undesired outcomes given the current state of knowledge. B. Quality Improvement Definition: The process of attaining a new level of performance or quality that is superior to any previous one. C. Total Quality Management Definition: A management philosophy that emphasizes a commitment to excellence throughout the organization. D. Six characteristics of total quality management 1. Customer/patient focus 2. Focus on outcomes 3. Total organizational involvement 4. Multidisciplinary approach 5. Use of quality tools and statistics for measurement 6. Identification of key areas for improvement E. Mandated by the Joint Commission on Accreditation of Health Care Organizations III. Nursing Care Delivery Systems A. Functional Nursing (Task Nursing) 1. Needs of patients are broken down into tasks 2. Tasks are assigned to various levels of health care workers according to licensure and skill 3. Example: RNs assess patients while nursing assistants give bed baths B. Team Nursing 1. Most common nursing care delivery system 2. A team of nursing personnel provides total patient care to a group of patients 3. Team leaders supervise patient care teams 4. Team leader reviews patients' plans of care and progress with team members during team conference C. Total Patient Care (Case Method) 1. A registered nurse is responsible for all aspects of care of one or more patients 2. Currently this type of care is provided in areas requiring high level of nursing expertise such as the critical care unit or the post- anesthesia recovery units D. Primary Nursing: 1. The registered nurse maintains a patient load of primary patients 2. The primary nurse designs, implements and is accountable for the nursing care of those patients during their entire stay on the unit E. Practice Partnerships: 1. An RN and an assistant (UAP, LPN/LVN or less experienced RN) agree to be practice partners 2. Partners work together on same schedule with same group of patients 3. Senior partner directs the work of the junior partner within the scope of each partner’s practice F. Case Management: 1. Model for identifying, coordinating and monitoring the implementation of services needed to achieve desired patient outcomes within a specified period of time 2. Organizes patient care by major diagnoses or diagnostic-related groups (DRGs) 3. A collaborative practice team defines the expected outcomes of care and care strategies for a patient population by defining critical paths 4. A nurse manager is assigned to coordinate, communicate, collaborate, problem solve, facilitate and evaluate patient care for a group of patients 5. Case manager usually does not provide direct patient care but supervises care provided by licensed and unlicensed nursing personnel according to critical G. Differentiated Practice: 1. Identifies distinct levels of nursing practice based on defined abilities that are incorporated into job descriptions 2. Structures nursing roles according to education, experience, and competency H. Patient-Centered Care: 1. Nurse coordinates a team of multifunctional unit-based caregivers 2. All patient care services are unit-based, including admission, discharge, diagnostic testing and support services 3. Uses unlicensed assistive personnel to perform delegated patient care tasks Be Prepared Arrive at the testing center early so you have time to register, become accustomed to your surroundings, and to relax. Bring the proper identification and your Authorization To Test (ATT). IV. Documentation A. Six key aspects of effective documentation Get a clue Documentation has six key aspects: CO-ACTS 1. Confidential 2. Organized 3. Accurate 4. Complete 5. Timely 6. Subjective and objective data B. Types of Documentation 1. Problem-Oriented Medical Record (POMR) 2. Narrative Documentation 3. Focus Charting 4. Charting by Exception Get a clue Don't Confuse: Scope of Practice (the state) Standards of Practice (the nursing profession) Standard of Care (the institution) V. Nurse Practice Acts Definition: Passed by each state legislature to regulate the practice of nursing in that state. A. Nurse Practice Acts define 1. Scope of practice 2. Education 3. Licensure 4. Professional misconduct a. Negligence b. The impaired nurse c. The nurse who violates boundaries B. Administered by the board of nursing in each state 1. The nurse must know how his/her state defines professional misconduct 2. For professional misconduct, state board of nursing imposes penalties (in order of severity): a. On probation b. Censured c. Reprimanded VII. License suspended Negligence Definition: Legally, a breach of the duty to provide nursing care to the client. A form of malpractice. The unintentional failure of an individual to perform or not perfom an act that a reasonable person would or would not perform in a similar set of circumstances. Malpractice is professional negligence. Negligence involves four legal concepts: A. Duty B. Breach of duty C. Proximate cause D. Damages Get a Clue Mr. X sues Nurse Jones for negligence. Mr. X must prove both that Nurse Jones both committed a breach of duty and that that breach of duty was the proximate cause of Mr. X's damages. E. Duty: Nurses have a legal obligation to provide nursing care to clients. 1. Must meet a reasonable and prudent standard of care under the circumstances 2. Must deliver care as any other reasonable and prudent nurse of similar education and experience would, under similar circumstances F. Breach of duty: Failure to provide expected, reasonable standard of care under the circumstances. Includes errors of omission or commission G. Proximate Cause 1. Relationship between the breach of duty and the resulting injury. 2. The injured party must prove that the nurse's action or omission led to the injury. H. Damages: the injury and the monetary award to the plaintiff Relax Get a good night's sleep the night before you take the NCLEX-RN. License revoked VI. Standards of Nursing Practice and Standard of Care A. American Nurses Association publishes its Standards of Nursing Practice, which define the responsibilities of the nurse to all clients for quality of care. B. Each institution sets standards of care, both across the institution and for specific clinical populations. VIII. Other Professional Misconduct A. The Impaired Professional 1. Remember that the impaired nurse is compromising client care. 2. Be sure that the problem exists and can be proven. 3. Document incidents, specific times, dates. 4. File a report according to the policies and procedures of the institution. 5. Urging an impaired co-worker to seek counseling is not enough. B. Boundary Violations 1. Definition: actions that overstep established interpersonal boundaries to meet the needs of the nurse 2. Guiding principles in determining professional boundaries: a. The nurse is responsible for setting and keeping boundaries. b. The nurse must avoid simultaneous professional and personal relationship with same person. c. The nurse must avoid flirtation. IX. Client's rights Get a Clue To help you remember the six client's rights: PARFIT Privacy Advance Directives Refusal of Treatment Freedom from Restraint Informed Consent Transition Plan A. Privacy 1. Confidential information may only be released by signed consent of the client 2. Unauthorized release of client data may be an invasion of privacy. 3. You must release information when a court orders, or when statutes require it (as in child abuse or communicable diseases). 4. Special regulations apply to release of information about psychiatric illness or HIV. B. Advance Directives (ADs) 1. The Omnibus Budget Reconciliation Act (OBRA) of 1990 requires states to provide advance directives as options to clients. 2. Varies by state. 3. Must be witnessed and on file; the only employee of a health care organization who may be the signing's legal witness is a clinical social worker. It is at the discretion of each health care facility as to whether or not this is done. A policy should be written. Always check the policy of your facilty. 4. Durable power of attorney - appoints a decision maker 5. Living Will - specifies what life prolonging the person wishes 6. Do Not Resuscitate (DNR) status Living Will A living will indicates the client's wishes regarding 1. Prolonging life using life support measures 2. Refusing or stopping medical interventions 3. Making decisions about his or her medical care A living will is executed while the client is competent and able to make sound decisions. As conditions change, a living will needs to be evaluated for relevance C. Refusal of Treatment - Competent clients may refuse treatment, even life- sustaining treatment D. Freedom from Restraints 1. Physical restraints require a signed, dated physician's order specifying the type of restraint and a time limit 2. Types of restraints a. chemical b. physical 3. Use the least restrictive form of restraint. 4. Guidelines for restraint use 5. You must document three factors a. Why you used restraint b. How the client responded c. Whether the client needs continued restraint 6. Restraining clients without consent or sufficient justification may be interpreted as false imprisonment. E. Informed Consent 1. Basic requirements: a. Capacity b. Voluntariness c. Information 2. The client must understand: a. Purpose of the procedure and expected results b. Anticipated risks and discomforts c. Potential benefits d. Any reasonable alternatives e. That he/she may withdraw consent at any time 3. The physician has the legal obligation to obtain informed consent for medical treatment, but the nurse should confirm consent and answer the client's questions. F. Transition Planning - Recognizes that clients are not discharged from care but moved across the continuum to another level. Guidelines for Restraints Health care providers can legally restrain a client under certain conditions defined by the law and by the health care facility’s policies and procedures. The restraints must be necessary to meet the client’s therapeutic needs or to ensure the safety of the client or others. The least restrictive type of restraint must be used first. Use of restraints must be accompanied by the physician’s orders except in an emergency. The client must be closely monitored when in restraints. Restraints should be released periodically and the skin integrity of the area being restrained assessed. Document all pertinent details including why the restraints are being used and client's response. Make sure that the orders for restraints are written and updated according to the policy of the facility. Informed Consent A mentally competent adult client must give his/her own consent; parents or legal guardians may give consent for minors. Clients need to understand: 1. purpose of the procedure 2. any reasonable alternatives 3. risks, consequences, and benefits of the procedure and the alternative(s) 4. risk if the treatment is refused The physician has the legal obligation of obtaining a client's informed consent to medical treatment. The nurse is often assigned the task of obtaining a signed consent form and witnessing the client’s signature. The nurse who is concerned about the validity of an informed consent has a legal obligation of telling the physician and the nursing supervisor about the concern. X. Ethics in Nursing A. Ethics 1. Science that deals with principles of right and wrong, good and bad 2. It governs our relationships with others 3. Based on personal beliefs and values B. Principles 1. Respect for Persons 2. Respect for Autonomy 3. Nonmaleficence and Beneficence 4. Justice 5. Truthfulness 6. Confidentiality 7. Fidelity Nursing practice is governed by legal restrictions and professional standards. What you as a nurse can do depends on the nurse practice act in the state in which you are licensed. Each state defines what constitutes professional misconduct. The state board of nursing has the authority to impose a penalty for professional misconduct. Penalties include probation, censure, reprimand, suspension or revocation of the license. Standards of nursing practice apply to all nurses in all practice settings. Standards of care are based on facility policy and procedure, nursing education, experience, and publications of professional nursing associations and accrediting groups. To Avoid Negligence: 1. Know the standard of care 2. Deliver care that meets the standard and follows the facility’s policies and procedures. 3. Document care accurately The only employee of a health care organization who may be the legal witness to the signing of an advance directive is a clinical social worker. It is at the discretion of each health care facility as to whether or not this is done. Always check the policy of your facility. A relative or heir to the estate should never be the witness to the signing of an advance directive. Ethics guide the nurse toward client advocacy and the development of a therapeutic relationship. Ethical dilemmas result from conflicts in values. An effective leader modifies his/her style according to the situational requirements. Final responsibility for any delegated task resides with the registered nurse. The registered nurse must monitor delegated tasks and evaluate the outcomes critical pathway A guide that outlines the optimum sequencing for interdisciplinary patient care to ensure consistency and continuity QUIZ ON DELEGATION Question 1 As the RN responsible for a client in isolation, Answers Correct A which of the following tasks can be delegated Student's A to the Unlicensed Assistive Personnel (UAP)? * A) Reinforcement of isolation precautions Assessment of the client's attitude about B) infection control Evaluation of visitors’ compliance with C) control measures Observation of the client's total D) environment Review Information: The correct answer is: A) Reinforcement of isolation precautions. Unlicensed personnel may reinforce the teaching of the RN. Fisher, M. (2000). Do you have delegation savvy? Nursing 2000, 30 (12), 58 Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes. Philadelphia: W.B. Saunders., p. 344 Question 2 An Unlicensed Assistive Personnel (UAP), Answers Correct C who usually works in pediatrics is assigned to Student's C work on a medical-surgical unit. Which one of the questions by the charge nurse would be most appropriate prior to making delegation decisions? A) "How long have you been a UAP?” "What type of care did you give in B) pediatrics?” "Can we review your competency * C) checklist?” "Are you comfortable caring for adult D) clients?” Review Information: The correct answer is: C) "Can we review your competency checklist?”. The UAP must be competent to accept the delegated task and the right task must be delegated to the UAP. Yoder-Wise, P. (1999) Leading and Managing in Nursing,. St. Louis: Mosby. National Council of State Boards of Nursing (1995). Delegation: Concepts and decision making process. Question 3 A client has had a tracheostomy for one week Answers Correct D following a motor vehicle accident. Which one Student's D of the following could the RN safely delegate to Unlicensed Assistive Personnel (UAP)? A) Administer oxygen by cannula B) Evaluate breath sounds C) Observe for signs of respiratory distress * D) Perform routine tracheostomy care Review Information: The correct answer is: D) Perform routine tracheostomy care. Unlicensed assistive personnel should be able to perform routine tracheostomy care. Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes. Philadelphia: W.B. Saunders., p. 1657 Shea, C., Pelletier, L., Poster, E., Stuart, G.& Verhey, M. (1999). Advanced practice nursing in psychiatric and mental health care. St. Louis: Mosby.p. 176 Question 4 It is important that the RN determine the Answers Correct B competence of the Unlicensed Assistive Student's B Personnel (UAP) assigned to the unit’s health care team. When interviewing a potential UAP employee who just completed the agency orientation, which one of the following questions would be the BEST to assess competence? A) Do you need supervision for basic care? * B) Can we review your skills check-list? Are you comfortable working C) independently? D) What client care tasks do you prefer? Review Information: The correct answer is: B) Can we review your skills check-list?. The nurse needs to know that the UAP has competence in certain tasks. One way to do this is to review documented skills. Fisher, M. (2000). Do you have delegation savvy? Nursing 2000, 30 (12), 58 Shea, C., Pelletier, L., Poster, E., Stuart, G.& Verhey, M. (1999). Advanced practice nursing in psychiatric and mental health care. St. Louis: Mosby. p. 176 Question 5 The care of which of the following clients can Answers Correct A be safely delegated to a nursing assistant? Student's C A client with peripheral vascular disease * A) and an ulceration of the lower leg. A pre-operative client awaiting B) adrenalectomy with a history of asthma An 82 year-old client with hypertension C) and self-reported non-compliance A new admission with a history of D) transient ischemic attacks and dizziness Review Information: The correct answer is: A) A client with peripheral vascular disease and an ulceration of the lower leg.. This client has a chronic condition, and needs supportive care. Yoder-Wise, P. (1999) Leading and managing in nursing, 2nd edition. New York: Mosby. Grohar-Murray, M. & DiCroce, H. (1997) Leadership and management in nursing, 2nd edition. Stamford, CT: Appleton & Lange. Question 6 The nurse in the same day surgery unit assigns Answers Correct D the Unlicensed Assistive Personnel (UAP) to Student's D give a soap solution enema (SSE) to a client scheduled for an abdominal hysterectomy. Which one of the following statements by the nurse is most appropriate? "Administer enemas until the results are A) clear." B) "Give three enemas before surgery." C) "Let me know the results of the enema." "Slow the flow of the solution if * D) cramping occurs." Review Information: The correct answer is: D) "Slow the flow of the solution if cramping occurs.". The professional nurse can delegate tasks with an expected outcome. The UAP is given adequate information about the procedure. Hansten, R. & Washburn, M. (1994). Clinical Delegation Skills. Gaithersburg, MD : Aspen. Yoder-Wise, P. (1999) Leading and Managing in Nursing,. St. Louis: Mosby. Question 7 An RN from the women’s health clinic is Answers Correct B temporarily reassigned to a medical-surgical Student's B unit. Which one of the following client assignments would be most appropriate for the reassigned or float nurse? A newly diagnosed diabetic learning A) foot care A motor vehicle accident (MVA) client * B) with an external fixation device on the leg A client in for a swallowing test after a C) transient ischemic attack (TIA) A newly admitted client with a diagnosis D) of pancreatic cancer Review Information: The correct answer is: B) A motor vehicle accident (MVA) client with an external fixation device on the leg. This client is the most stable, requires basic safety measures and has a predictable outcome. Yoder-Wise, P. (1999) Leading and Managing in Nursing,. St. Louis: Mosby American Association of Critical Care Nurses (1990). Delegation of nursing and non-nursing activities in critical care: A framework for decision makiang. Laguna Viquel, CA: AACN. Question 8 The home care nurse has been supervising a Answers Correct B client for six weeks. What is the BEST method Student's B to determine the quality of care provided by a home health care aide assigned to assist with the care of this client? Ask the client and family if they are A) pleased with the home health aide's care Determine if the home health aide is * B) following the plan of care Know if the home health aide arrives on C) time and stays the appropriate length of time Check to see if the home health aide is D) documenting appropriately Review Information: The correct answer is: B) Determine if the home health aide is following the plan of care. Although the nurse must complete all of the above responsibilities, following the plan of care is the first priority. The plan of care is based on the reason for referral, physicians'' orders, the initial nursing assessment, responses to health care providers'' interventions, and the client''s and family''s requests. Scheet, N.J. (1995). HHA Supervision: Another View. Home Health FOCUS, 1(12), 6. Martin, KS., Harkness, G. & Dincher, J. (1996). Home Health Care. Medical-Surgical Nursing: Total client Care. St. Louis: Mosby. Question 9 Which one of the following clients would be Answers Correct B most appropriate to assign an LPN? Student's B A trauma victim with multiple A) lacerations requiring complex dressings. An elderly client with cystitis and an * B) indwelling Foley catheter. C) A confused client whose family complains about care following surgery. A client admitted for possible CVA with D) unstable neuro signs. Review Information: The correct answer is: B) An elderly client with cystitis and an indwelling Foley catheter.. This is a stable client, with predictable outcome and care. Yoder-Wise, P. (1999) Leading and Managing in Nursing,. St. Louis: Mosby Hansten, R. & Washburn, M. (1994). Clinical Delegation Skills. Gaithersburg, MD : Aspen. Question 10 A 25 year-old client, unresponsive after a Answers Correct D motor vehicle accident, is being transferred Student's D from the hospital to a long term care facility. To which one of the following staff members should the nurse assign the client? A) An LPN B) A nursing assistant C) A nursing student * D) An RN Review Information: The correct answer is: D) An RN. The RN is responsible for teaching and assessment associated with discharge and these activities cannot be delegated. Yoder-Wise, P. (1999) Leading and Managing in Nursing,. St. Louis: Mosby Hansten, R. & Washburn, M. (1994). Clinical Delegation Skills. Gaithersburg, MD : Aspen. Question 11 You are the charge nurse on a team with 2 Answers Correct C RNs, 1 licensed practical/vocational nurse and Student's C 1 nursing assistant. Which of the following clients would be most appropriate to assign to the licensed practical nurse? A quadriplegic trauma victim and a A) client 1 day following radical neck dissection. A newly diagnosed diabetic and a client B) with AIDS admitted for pneumonia. A hemiplegic fed by a nasogastric tube * C) and an amputee in rehabilitation. A schizophrenic in alcohol withdrawal D) and a client in chronic renal failure. Review Information: The correct answer is: C) A hemiplegic fed by a nasogastric tube and an amputee in rehabilitation.. These clients require supportive care and interventions within the scope of practice of a licensed practical nurse. Yoder-Wise, P. (1999) Leading and managing in nursing, 2nd edition. New York: Mosby. Grohar-Murray, M. & DiCroce, H. (1997) Leadership and management in nursing, 2nd edition. Stamford, CT: Appleton & Lange. Question 12 A licensed practical nurse (LPN) from the Answers Correct D pediatric unit is assigned to work in the ICU. Student's D Which one of the following client assignments would be most appropriate? A trauma client with a newly implanted A) pacemaker. A 53 year-old client with a possible B) myocardial infarction. C) A new admission with left sided weakness from a stroke A 35 year-old in traction after a motor * D) vehicle accident. Review Information: The correct answer is: D) A 35 year-old in traction after a motor vehicle accident.. This client is the most stable with a predictable outcome. Hansten, R. & Washburn, M. (1994). Clinical Delegation Skills. Gaithersburg, MD : Aspen. Yoder-Wise, P. (1999) Leading and Managing in Nursing,. St. Louis: Mosby Question 13 The charge nurse on a cardiac step-down unit Answers Correct B makes assignments for the team consisting of Student's C an RN, an LPN, and a nursing assistant. Which one of the following clients should be assigned to the LPN? A 49 year-old with new onset atrial A) fibrillation. A 58 year-old hypertensive with * B) possible angina. A 35 year-old scheduled for cardiac C) catheterization. A 65 year-old for discharge after D) angioplasty and stent placement. Review Information: The correct answer is: B) A 58 year-old hypertensive with possible angina.. This is the most stable client. Yoder-Wise, P. (1999) Leading and Managing in Nursing,. St. Louis: Mosby Hansten, R. & Washburn, M. (1994). Clinical Delegation Skills. Gaithersburg, MD : Aspen. Question 14 The measuring and recording of vital signs is Answers Correct C routine for clients in a long-term facility. To Student's C whom could these tasks be delegated? A) Licensed practical nurse B) Registered Nurse * C) Nursing assistant D) Volunteer Review Information: The correct answer is: C) Nursing assistant. The measurement and recording of routine vital signs may be delegated to a nursing assistant. Critical considerations for delegating care to unlicensed assistive personnel (UAP) would be: Who is capable and is the least expensive worker to do each task? Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes. Philadelphia: W.B. Saunders., p. 183, 100 Question 15 Which one of the following statements by the Answers Correct A nurse is best when assigning an Unlicensed Student's A Assistive Personnel (UAP) to ambulate a client for the first time after a colon resection? "Have the client sit on the side of the * A) bed before helping him to walk." "If the client is dizzy ask him to take B) some slow, deep breaths." "Help the client to walk in the room as C) often as he wishes." "When you help the client to walk, ask D) him if he has pain." Review Information: The correct answer is: A) "Have the client sit on the side of the bed before helping him to walk.". This statement gives clear directions to the UAP about the task. Hansten, R. & Washburn, M. (1994). Clinical Delegation Skills. Gaithersburg, MD : Aspen. Yoder-Wise, P. (1999) Leading and Managing in Nursing,. St. Louis: Mosby. Question 16 When walking past a client’s room, the nurse Answers Correct B hears one nursing assistant talking to another. Student's B Which one of the following statements requires nursing intervention? "If we work together we can get all of A) the client care completed." "Since I am late for lunch, would you do * B) his glucose test?" "This client seems confused, we need to C) watch him carefully." "I’ll come back and make the bed after I D) go to the lab." Review Information: The correct answer is: B) "Since I am late for lunch, would you do his glucose test?". Only the professional nurse can delegate. The nursing assistant can not delegate a task to another. The RN is legally accountable for nursing care. Hansten, R. & Washburn, M. (1994). Clinical Delegation Skills. Gaithersburg, MD : Aspen. Yoder-Wise, P. (1999) Leading and Managing in Nursing,. St. Louis: Mosby. Question 17 The nurse is caring for a confused client with Answers Correct B anemia. Which one of the following tasks Student's B could the nurse delegate to the Unlicensed Assistive Personnel (UAP)? A) Assess skin color changes * B) Test stool for occult blood C) Discuss food high in iron D) Observe for mental status changes Review Information: The correct answer is: B) Test stool for occult blood. The UAP can do standard, unchanging procedures. ANA (1996) Registered Professional Nurses & Unlicensed Assistive Personnel (2nd ed.). ANA: Washington, DC. National Council of State Boards of Nursing (1995). Delegation: Concepts and decision making process. Question 18 The RN delegates the task of taking vital signs Answers Correct D of all the clients on the medical-surgical unit Student's D to an Unlicensed Assistive Personnel (UAP). Specific instructions are given to avoid taking a post-mastectomy client’s blood pressure on the left arm. Later as the RN is making rounds, she finds the blood pressure cuff on that client’s left arm. Which one of the following statements is most accurate? A) The RN is accountable for this situation. B) The RN did not delegate appropriately. The UAP is covered by the RN’s C) license. The UAP is responsible for following * D) instructions. Review Information: The correct answer is: D) The UAP is responsible for following instructions.. The UAP is responsible for carrying out the activity correctly once directions have been clearly communicated. Yoder-Wise, P. (1999) Leading and Managing in Nursing,. St. Louis: Mosby Hansten, R. & Washburn, M. (1994). Clinical Delegation Skills. Gaithersburg, MD : Aspen. Question 19 The nurse assigns an Unlicensed Assistive Answers Correct B Personnel (UAP) to care for a client with a Student's D musculoskeletal disorder who ambulates with a leg splint. Which one of the following tasks requires supervision? Reporting signs of redness overlying a A) joint Monitoring the client's response to * B) activity. C) Encouraging independence in self-care Assisting the client to transfer from a D) bed to a chair Review Information: The correct answer is: B) Monitoring the client''s response to activity.. Monitoring the client’s response to interventions requires assessment, a task to be performed by an RN. Fisher, M. (2000). Do you have delegation savvy? Nursing 2000, 30 (12), 58. Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes. Philadelphia: W.B. Saunders., p. 573 Question 20 Which one of the following can be safely Answers Correct C delegated to a nursing assistant? Student's C Assessing function of a newly created A) ileoostomy. Caring for a client with a recent double B) barrel colostomy. Providing stoma care for a client with a * C) well functioning ostomy. Teaching self care of the ostomy to a D) client and family. Review Information: The correct answer is: C) Providing stoma care for a client with a well functioning ostomy.. The care of a mature stoma and the application of an ostomy appliance may be delegated to a nursing assistant. This implementation task does not require independent judgment. Fisher, M. (2000). Do you have delegation savvy? Nursing 2000, 30 (12), 58 Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes. Philadelphia: W.B. Saunders., p. 778 Question 21 Which of the following client data should the Answers Correct C nurse instruct the home health aide to consider Student's C a PRIORITY and call the nurse from the client's home to report? Complains of not sleeping well last A) night B) Wants to discontinue Meals on Wheels Evidence of blood in the client's urinary * C) catheter bag Complains of not getting along with D) neighbors Review Information: The correct answer is: C) Evidence of blood in the client''s urinary catheter bag. Although home health aides need to report diverse information to nurses through phone calls and documentation, they need to report signs and symptoms immediately that suggest serious changes in clients'' conditions. The nurse who develops the plan of care for a specific client and supervises the aide must identify potential danger signs which require immediate reporting, and determine if the aide reports data appropriately. Scheet, N. J. (1995). HHA Supervision: Another View. Home Health FOCUS, 1(12), 6. Harkness, G. & Dincher, J., & Martin, K.S. (1996). Home Health Care, Medical-Surgical Nursing: Total client Care. St. Louis: Mosby. Question 22 A staff nurse complains to the nurse manager Answers Correct C that a nursing assistant consistently leaves the Student's C work area untidy and does not restock supplies. The BEST initial response by the nurse manager is to Arrange for a conference with both A) employees Assure the nurse that the complaint will B) be investigated Suggest that the nurse approach the * C) assistant about the problem Add this concern to the agenda for the D) next unit meeting Review Information: The correct answer is: C) Suggest that the nurse approach the assistant about the problem. Helping staff manage conflict is part of the manager''s role. It is appropriate to urge the nurse to confront the other to work out problems without a manager''s intervention when possible. Marquis. B. L. & Huston, C. J. (1999). Leadership Roles and Management Functions in Nursing. Philadelphia: Lippincott-Raven Publishers. Yoder Wise, P. S. (1995). Leading and Managing in Nursing. St. Louis: Mosby. Question 23 Two people call in sick on the medical- Answers Correct D surgical unit and no additional help is Student's D available.. The team consists of an RN, an LPN and an Unlicensed Assistive Personnel (UAP). Which one of the following activities should the nurse assign to the UAP? Discharge planning for a client with a A) transient ischemic attack (TIA). Administering oral medications to all B) clients on the unit. Assessing a client after an acute C) myocardial infarction Providing basic hygiene care to all * D) clients on the unit. Review Information: The correct answer is: D) Providing basic hygiene care to all clients on the unit. Only basic client care can be delegated to a UAP Hansten, R. & Washburn, M. (1994). Clinical Delegation Skills. Gaithersburg, MD : Aspen. Yoder-Wise, P. (1999) Leading and Managing in Nursing,. St. Louis: Mosby. Question 24 A client is receiving an intravenous (IV) Answers Correct D infusion. When caring for this client, which Student's D one of the following actions can the RN safely ask an Unlicensed Assistive Personnel (UAP) to perform? A) Adjust the flow rate B) Monitor pump operation C) Change the IV as needed * D) Report a fluid level of 200 ml Review Information: The correct answer is: D) Report a fluid level of 200 ml. When directing the UAP, communicate clearly and specifically what the task is and what should be reported to the nurse. Only implementation tasks should be delegated since they do not require independent judgment. Fisher, M. (2000). Do you have delegation savvy? Nursing 2000, 30 (12), 58-60. Shea, C., Pelletier, L., Poster, E., Stuart, G.& Verhey, M. (1999). Advanced practice nursing in psychiatric and mental health care. St. Louis: Mosby. p. 176 Question 25 An RN is making out assignments in the long Answers Correct D term care facility. Which one of the following Student's D assignments to an Unlicensed Assistive Personnel (UAP), if made by the nurse, requires an intervention by the supervisor? Providing decubitus ulcer care and A) applying a dry dressing B) Bathing and feeding a client on bed rest Oral suctioning of an unresponsive C) elderly client Teaching a family intermittent (bolus) * D) feedings before discharge Review Information: The correct answer is: D) Teaching a family intermittent (bolus) feedings before discharge. Teaching can not be delegated and must be done by the professional nurse. Hansten, R. & Washburn, M. (1994). Clinical Delegation Skills. Gaithersburg, MD : Aspen. ANA (1996) Registered Professional Nurses & Unlicensed Assistive Personnel (2nd ed.). ANA: Washington, DC.
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