Capstone final study Questions and Answers correct

Capstone final study Questions and Answers correct Finding a client sitting on the floor, nurse calls for help from UAP get BP cuff Assigning a UAP to assist client with personal care prescribed activity level The ICU is full and short staffed, so nursing super informs charge nurse in the med dept that one nurse must float to the ICU staff who was cross trained to work in the critical care dept Charge nurse developing guidelines for a coronary care unit The scope of standards of practice from the American nurses association Which patient should be assigned to a nurse that is floated from maternity unit post op hysterectomy There has been a major disaster. Triage nurse should give which patient priority Cut over eye Delegate to LPN Dressing change Move which patient to medical surgical unit Patient with ABNL liver levels One open bed in ICU but reserved for patient coming from PACU with respiratory problems, what to do Take patient to ICU and arrange for respiratory patient to stay in PACU UAP giving complete bath-which patient is more concern Patient with dyspnea (SOB when lying flat) ER nurse getting moved to L&D, what patient should leader assign Patient with episiotomy infection DNR Notify the family Against medical Advice (AMA)with and IV RN removes IV, sign the document AMA form Prescriptions-telephone repeat order back to doctor to make sure it is correct Assign UAP hygiene, feeding, ADLS, ROM, ambulation Confidentiality-emergency department don't give out information about patient, don't talk about patients condition in front of people, keep records safe Malpractice negligence by professional personnel Ex: buring client with hot heating pad, ignoring s/s of bleeding, giving wrong medication Patient bill of rights show pt there bill of rights, they have the right to see their chart and anything regarding their care Assign PN-scope of practice No assessments, teaching (newly DX'd), IV's, blood transfusions, no suicide patients, no critical patients Assignments-new grad graduate nurse supervised by RN, what pt to give? Infusing antibiotic or choosing catheter port Unsafe nurse after nurse goes through rehab she can do her job regularly Brain death-organ donation if person is organ donor and is brain dead, organs can be donated Critical lab value high levels or low levels (know levels) potassium is a priority lab value Fibromyalgia assistance provide uninterrupted sleep and refer to pain specialist RN role-assess RN's assess not LPN or UAP Med error- action assess pt, incident report, notify doctor, document amt prescribed, and dosage given MRSA room assigned private room, contact isolation Restraints standards of care Cultural Native American POC Know rules for Immunization permission Priority care Management Ethical Assign least care to UAP Consent to treat without consent Pt having sex in hospital room Close the door Clients rights to give Informed consent is based on which ethical principle Autonomy Conflict resolution-nurses Ask the nurses to meet with the nurse manager to identify ways of working CPR Evaluate effectiveness Delegation-PN An elderly client with Alzheimer's disease complicated by dysphagia (assign to LPN) Pain management issue Teach patient how to use PCA NGT Irrigation-assignment RN must irrigate UAP using a hand sanitzers that is alcohol for 2 minutes tell that hand sanitizer use is less 2min charge nurse developing the nursing guidelines for a coronary care unit The Scope of Standards of Practice from the American Nurses Association nurse-manager is preparing an annual budget for the unit. Nursing salaries should be included in which component of the budget Operating budget nurse has not finished administering routine oral medication because one pt experienced chest pain and another rectal bleeding. It is now dinner time and two clients must be fed. The unlicensed assistive personnel (UAP) is filling water pitchers and the practical nurse (PN) is charting vital signs. Which change in assignments is best UAP feed the two clients, PN finish oral medications and RN monitor clients with chest pain and rectal bleeding reporting blood glucose results to the nurse the LPN says the glucometer was not calibrated prior to use because the report given by the night shift staff ran late Advise the LPN of the implications involved by not calibrating the glucometer Risk management: pt fell while using some equipment charge nurse trying to find out what happened- hospital polices New RN to Unit best client to assign is client 4 days post MI Incorrect Delegation LVN/LPN to remove staples from abdominal wound Client in labor, you call the provider and he has slurred words, loud noise in background, and seems intoxicated contact the healthcare provider's associate, not the medical director What source states the legal requirements nurses must follow to protect client confidentiality in a nurse-patient relationship State Nurse Practice Acts nurse-manager of a perinatal units is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions A 35-year-old with lupus erythematosus female with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chonic pain- interdisciplinary team member Pain specialist What action should the nurse implement first when delegating nursing activities to an unlicensed assistive personnel (UAP) Evaluate the experience of the UAP male with cancer admitted to the oncology unit tells the nurse that he is in the hospital for palliative care measures but ordered prescriptions include radiation therapy Consult with the client about his expected goals for his hospitalization and current treatment plan nurse behavior is a breach of clients confidentiality according to the Health Insurance Portable Accountability Act (HIPAA) regulations Take home a daily report sheet with the information of the team's client on a surgical unit nurse receives a personal phone call about a family emergency that requires the nurse to leave immediately Notify the charge nurse of the situation and of the need and leave immediately If you see a nurse make a mistake-Chain of command speak to her before going to management. If the situation persists, then take it higher LVN/LPN can't Handle any blood 1. Newly hired UAP expresses fear to collect a sputum from HIV patient Determine the UAP's knowledge about HIV transmission. 2. RN, PN, UAP are working as a team The UAP obtains an oxygen saturation level while RN reports finding to the health care provider. 3. The most immediate follow-up An UAP is assigned to check a client for fecal impaction. 4. Nurse receives a prescription over the telephone Administer a nebulizer breathing treatment. 5. Patient uses the call system alarm Ask a coworker to respond to the client whose call bell is alarming. 6. Emergency room, who to take care first A female client with severe right lower abdominal pain who is febrile and vomiting. 7. No heroic measures Give detailed report to accepting nurse. 8. Evaluate cardiac monitor system Organize a committee of ICU nurses to identify potential problems of the new monitoring system. 9. Client has reported feeling of being constipated Assist the client to drink warm prune juice. 10. Sequential compression devices Report any change in color in the client's feet or legs. 11. Respiratory therapist cross-trained avoiding HIV positive client Provide the employee with feedback about the observed behavior. 12. Medication error remains unchanged Examine medication administration data to determine use of new policy by nursing staff. 13. Increase of nurse-to-patient ratio by 25% Disseminate factual information to all nursing staff to avoid misinformation and rumors. 14. Calculation: 10080FTEs / 72 hours 18 15. Respiratory rate decreases 14/ min - 6/ min - 4/min The decision regarding when to call the health care provider 16. Glucometer checks post 2 days consistently 50-60 mg/dl higher Evaluate calibration of glucometer in use per manufacturer guidelines. 17. Receptionist is responsible for taking client calls. Who to call back first? Casted right leg has a funny feeling tingling sensation. 18. Two clients in one room. One client has MRSA the other one neutropenia. What intervention should the nurse implement? Transfer client with neutropenia to a private room. 19. Signed witnessed DNR Confirm current resuscitation wishes with client and family 20. Staffing formula based on what? Skills of staff and client acuity. 1. hospice nurse end of life care- MUCOUS MEMBRANE MOIST