Which task related to the use of patient restraints can be delegated to assistive personnel (ap)

REALIZAR TEST

Título del test:
Fundamentals Final Test 2020

Descripción:
Fundamentals Final 2020

Autor:
Gabby
(Otros tests del mismo autor)

Fecha de Creación:
20/04/2020

Categoría:
Otros

Número preguntas: 89

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Temario:

A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality? Reporting laboratory findings to a member of the client's family jaahjj.
A nurse is caring for a client whose family is in a state of disagreement over the care of their family member. The nurse should report the situation to which of the following facility personnel? -Hospital ethics committee -Quality improvement committee Clinical education specialist -Hospital administration.
A nurse is working with an assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing? -Removing the abdominal dressing iiiiiii.
A charge nurse is making client care assignments. Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? (SATA) Bathe a client who had an amputation 2 days ago, assist a client to ambulate using a gait belt and feed a client who had a stroke 3 months ago kkkkk.
Which hospitalized patient will the nurse assign to the room closet to the nurse’s station? - Patient with Alzaheimer disease who has long-term memory deficit - Patient with vascular dementia who takes medications for depression - Patient with new – onset confusion, restlessness, and irritability after surgery.
A nurse is preparing an inservice presentation for a group of newly licensed nurse about restraints. which should the nurse include as criterion for applying restraints - the nurse has already considered alternatives to restraints. iiiiii.
A nurse is caring for a client who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied. Which of the following statements by the nurse is appropriate? -"I will move the tube so he cannot see it." ooooo.
A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching? -"It is a good idea to use the handrails in the bathroom." jjjjjj.
As part of an annual physical exam, nurse is preparing a client to undergo a chest x-ray. which of the following instructions should the nurse give the client prior to the procedure? -remove all metal necklaces hhjhj.
A nurse is providing dietary teaching to an Asian-American client who is gazing at the floor during the instruction. Which of the following actions would demonstrate culturally sensitive nursing care? Continuing with the discussion kkkkk.
A nurse is about to explain a therapeutic procedure to a client who doesn't speak the same language as the nurse. Which of the following actions should the nurse take?: -Use nonverbal gestures to assure the client that the procedure is safe and will help him -Tell the client that he will receive written information in his language after the procedure -Have a medical interpreter present during the teaching -Ask a family member to translate.
A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds? -Laceration jjjj.
A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and feeling of bloating . Which of the following is the nurse’s priority action? -Check to see if the suction equipment is working. m mm,nn.
A nurse is instructing clients in the community about relationship development. The nurse should explain that, according to Erickson, establishing relationships with commitment is a primary task of which of the following stages of psychosocial development. -Intimacy vs isolation lllllll.
A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. -Room 208 is a private, negative-pressure airflow room yyyyyy.
A nurse is planning care for a client who requires airborne precautions. Which of the following actions should the nurse take? -N95 respiratory mask ooooo.
A nurse is planning care for a client who has manifestations of C. diff infection. Which of the following actions should the nurse plan to take? Place the client on contact precautions mmmmm.
A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? -Elevate the head of the client's bed 30 degree to 45 degree ,,,,,,,.
A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Which of the following of Erikson's developmental stages should the nurse consider in the planning? Industry vs. Inferiority kkkkkk.
A nurse is caring for a client who is scheduled for surgery. The nurse's role in regard to informed consent is which of the following? -Determining the client's level of understanding about the procedure kkkkk.
A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (select all that apply) -Document restraint checks and client status every 2 hr. -Educate the client's family about restraint use. -Obtain the provider's prescription renewal every 72 hr. -Implement passive range-of-motion exercises. -Release the restraint and reposition the client every 4 hr.
A nurse is planning care for a client who has become increasingly anxious and confused. Which of the following actions should the nurse include to avoid the use of physcial restraints? (select all that apply) -Elevate all side rails on the bed. -Ensure effective pain management. -Attend to the client's needs for toileting. -Assign the client to a room near the nurses' station. -Orient client frequently to the environment.
At what angle should you administer an intramuscular (IM) injection? -90 degrees kkkk.
A nurse is planning discharge of a client who has sleep apnea and requires bi-level positive airway pressure (BiPAP) at night. nuse should plan to consult with which of the following health care team members? -respiratory therapist kkk.
A nurse is caring for a client whose total parenteral nutrition (TPN) was stopped for an hour by mistake. After restarting the infusion pump, the nurse should watch the client carefully for the development of -shakiness and diaphoresis. nnnn.
A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider? Urine is cloudy after sitting in the urinal for 6 hr Urine output of 2,200 mL in the past 24 hr Urine output of 175 mL in the past 8 hr First voided urine in the morning has strong odor.
A nurse in a provider's office is collecting data from an older adult client who reports a sudden onset of urinary incontinence. The nurse should collect additional data to determine if the client has which of the following conditions? Urinary Tract Infection jjj.
A nurse is reviewing the urinalysis results of a client who reports urinary frequency and burning. Which of the following finding should the nurse report to the provider? Microscopic hematuria jjjj.
The patient had surgery and a urinary catheter. Eight hours after catheter removal and drinking fluids, the patient has not been able to void. What should the nurse do first to assess for urinary retention? -Bladder scan hhh.
A nurse is caring for a client who needs a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for Blood. gggg.
A nurse is reinforcing teaching to a client who is experiencing constipation. Which of the following should the nurse discuss as causes of constipation? - Excessive laxative use -Ignoring the urge to defecate -Inadequate fluid intake.
A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following? -Dysrhythmias jjj.
A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures? Footboard jjj.
Full thickness skin loss, subcutaneous fat may be visible. NECROTIC SUBCUTANEOUS TISSUE Stage III pressure ulcer:.
A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to the UAP who is assisting with the client’s care? -Implementing contact precautions when providing care for the client. yyy.
After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient’s coccyx(with a stage 3 pressure ulcer). After assessing the area, what should be included in the plan of care? -Reposition the client every 2 hours. ii.
A nurse is in the emergency room ER with a patient that was playing football and he collapsed and was dehydrated. The nurse did labs and recognize that these findings are consistent with which of the following conditions. -Dehydration (potassium 3.6mEq/l) k.
If a nurse is preparing medication and is called away to an emergency which of the following should she do? - lock the medications in a room and finish them when she returns. i.
What is the best way for the nurse to make sure that the right patient is receiving a prescribed drug when the patient is alert and oriented? ASKING THE CLIENT’S FULL NAME AND DATE OF BIRTH uu.
A nurse is collecting data on an intravenous site located in the left hand of an infant. Which of the following findings indicate an inflitration? Edema in the palm of the hand bb.
A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. which of the following interventions should the nurse take? -repeat auscultation after asking client to breathe deeply and cough m.
When planning delegation of tasks to an AP, a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation? The AP has the knowledge and skill to perform the task ff.
An assistive personnel (AP) comes to work with a new set of highly polished acrylic nails. The nurse takes the AP aside and explains that acrylic nails are not permitted on the health care unit. Which of the following statements should the nurse tell the AP? -"There is a higher risk of infection associated with acrylic nails." mmm.
The charge nurse is on a team with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care? give positive feedback directly to the AP mmm.
-monitor findings (as input to the RN's ongoing assessment), reinforce pt teaching from a standard care plan, perform tracheostomy care, suctioning, check NG tube patency, admin enteral feedings, insert urinary catheter, administer medications (except IVs meds). INSERTING A NASOGASTRIC TUBE FOR A CLIENT jjj.
A nurse is working with an assistive personnel (AP) who refuses a client assignment. When resolving this conflict, which of the following comments is appropriate for the nurse to make? -"I need to talk to you about the unit policies regarding client assignments." yyy.
A nurse overhears two assistive personnel (AP) discussing a hospitalized client while in the cafeteria. Which of the following is the most appropriate nursing action? Sit at the APs' table and change the subject. Report the incident to the nurse manager. Quietly tell the APs that this is not appropriate. After lunch, discreetly remind the APs about client confidentiality.
A nurse should share her password for access to the facility's computer system with -no one uuu.
A nurse on the medical surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer? Observing a postoperative client who is confused Delivering mail trays to a client in their room Assisting a client who has difficulty seeing the foods on the tray while eating Delivering a routine urine specimen to the laboratory.
An assistive personnel (AP) tells the nurse manager that she observed a nurse on the unit removing a small amount of morphine from syringes prior to administering the medication to clients. Which of the following actions should the nurse manager take first? Approach the involved nurse to discuss the behavior. Notify the risk manager. Refer the nurse to the board of nursing diversion program. -Gather data about the nurse's work performance and attendance history. (The first action the nurse should take is to conduct an investigation and determine if the allegations are true.) .
A nurse manger is reviewing the Good Samaritan laws with a group of newly licensed nurses. Which of the following statements by the nurse manger is appropriate? Federal Laws require a licensed nurse to render aid in an emergency" If you render aid in an accident, do not leave the scene until another competent person can take over" Good Samaritan laws prohibit the victim from filing a lawsuit against the nurse" A nurse who volunteer at a summer camp for children is covered by Good Samaritan laws.".
A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report? A client discovers that his dentures are missing jjj.
A client who fell and broke his hip while assisted to the bathroom by a nurse states he plans to sue the nurse. the nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is what? Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation jjj.
A nurse is caring for a group of clients. The nurse demonstrates adherence to ethical principle of fidelity by doing which of the following? A nurse is caring for a group of clients. The nurse demonstrates adherence to ethical principle of fidelity by doing which of the following? -Keeping an appointment with a client jjj.
A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately? A toddler who has a laceration on his forehead and is screaming An adolescent female client who is belligerent and has slurred speech A middle adult male who is diaphoretic and reports epigastric pain A young adult with a painful sunburn of his face and arms.
A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.) The date of the incident. The name of the provider who prescribed the medication Te client’s vital signs. The time the client was to receive the The potential adverse effects of the medication.
A nurse is caring for an alert and competent older adult who comes to the hospital accompanied by her son for elective cataract extraction. Who should the nurse have sign the consent form for the surgical procedure? The client kkk.
A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make? have you talked to your parents about this yet "why do you think you are so anxious?" how long has this been going on?" "it sounds like you are having a difficult time".
A nurse is caring for a client who was involved in heavy combat and observed war casualties. THe nurse would suspect that the client is suffering from PTSD because? In my dreams all I can see are the wounded reaching out and trying to grab me." jjj.
A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic? I see you have done some grooming today" jjj.
An adolescent client in an emergency department reports being sexually assaulted just prior to admission. Which of the following actions should the nurse assessing the client take? Ask the client to describe the situation. jjj.
A nurse is caring for a client who suspects recent exposure to inhalation anthrax. Which of the following findings indicates possible exposure? -Flu-like symptoms jjj.
A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. which of the following responses by the nurse is appropriate? as a nurse, i'm required by law to report suspected child abuse." I reported the incident to my supervisor who decided to contact the authorities." The provider will be coming to explain the situation." I am unable to discuss this but can contact my supervisor to speak with you.".
A nurse is assessing a child and notes several bruises. which of the following actions should the nurse take report the suspected abuse to authorities Obtain a detailed history Ask a psychiatrist to talk to the parents Separate the child from the parents.
A nurse is providing Health promotion teaching to the parents of a toddler. What information should be included? Management of tantrums Dental Care.
A nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include? Have short teaching sessions j.
A nurse is preparing a presentaion at a senior center about age-related musculoskeletal changes. what should be included? Decreased muscle mass hhhh.
A nurse is reviewing a client’s lab results. Which of the following lab values should the nurse report to the provider? Sodium 126 meq/dl hhh.
A nurse manager is preparing to take disciplinary action for a staff nurse's substance use disorder. The manager should identify which of the following as having the authority to revoke a nurse's license? State Board of Nursing hhhh.
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? Reposition in a Sims' position with the client's weight on the anterior ilium. hhhh.
A client who has a nasogastric tube in place is prescribed a sublingual medication. Which of the following is an appropriate action by the nurse? Administer the medication under the client's tongue. Administer the medication in a liquid form orally. Administer the crushed medication trough the NG tube. Administer the medication dissolved in water through the NG tube.
A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication? -The client's sociocultural background influences nonverbal communication hhhh.
A nurse is discharging a pt who came to the outpatient clinic with an ankle sprain. which statements should the nurse identify as an indication the pt understands the discharge instructions? -"I'll apply ice to my ankle today and tomorrow" jjjj.
A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal? Temporary urinary retention gggg.
A nurse is caring for a client who is requesting prescription pain medication. Which of the following actions should the nurse perform first? Determine the location of the pain hhhh.
A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, "Go away; no one can help me." Which of the following responses should the nurse make? -"I will come back later and we can talk." jjjj.
A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching? -"I watch television until I fall asleep at night." jjjj.
A nurse enters a client's room ad finds her on the floor. The client's roommate reports that the client fell getting out of bed. Which of the following statements should the nurse document? client was found lying on floor." jjjj.
A nurse finds an opened vial of morphine sulfate lying on the cabinet in the client's room. Which of the following is an appropriate nursing action? -Report the discrepancy immediately jjjjj.
A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include? Bend at the knees when picking up an object jjj.
A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction? I can detect the presence of carbon monoxide by a metallic odor." hhh.
When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take? -Contact the provider to question the dosage jjj.
A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first? Assess the client jjj.
You are verifying placement of a nasogastric tube. Which gastric pH would indicate the tube is properly positioned? Select all that apply 6.0 5.0 2.0 3.0 RATIONAL: The normal gastric pH is between 1-4. Intestinal contents are above 6 and respiratory are above 5.5.
Which instruction might the nurse give to the NAP to help ensure that a wound culture specimen will be transported properly? -"Take this specimen to the lab immediately." jjj.
A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse rely on for accurate information about the client? Progress note Medical history Family information Client concerns.
A nurse is assisting with the admission of a client who is about to have elective surgery. The client tells the nurse she feels anxious. Which of the following responses should the nurse make? -"tell me more about your concerns." kkk.
A nurse is caring for a client who has an electrical burn. With the client's permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make? -"He has an electrical burn. He is stable, and we will update you with any changes." jjj.
A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements by the client indicates they understand and accept their prognosis? I am thinking of getting a second opinion." This is making me stronger every time." "I am hoping this will limit my discomfort." "This is not working and I plan to stop treatment.".

Which tasks related to the use of patient restraints can be delegated to assistive personnel?

Which task can be delegated to nursing assistive personnel?

Can assistive personnel apply restraints?

Which task can be delegated to nursing assistive personnel quizlet?