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HURST REVIEW Qbank /Customize Quiz-Leadership Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Select all that apply 1. Prepare a client's room for return from surgery. 2. Observe for£9.66
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HURST REVIEW Qbank /Customize Quiz-Leadership Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Select all that apply 1. Prepare a client's room for return from surgery. 2. Observe for
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Module
HURST
Institution
HURST
HURST REVIEW Qbank /Customize Quiz-Leadership 2023-
2024
Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive
personnel (UAP)?
Select all that apply
1. Prepare a client's room for return from surgery.
2. Observe for pain relief in a client after receiving ...
Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive
personnel (UAP)?
Select all that apply
1. Prepare a client's room for return from surgery.
2. Observe for pain relief in a client after receiving acetaminophen with codeine.
3. Assist a client with perineal care after having diarrhea.
4. Clean nares around a client's nasogastric (NG) tube.
5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy
(PEG).
1., 3, & 4. Correct. These are appropriate tasks for an UAP to complete. The UAP can
provide hygiene needs to a client such as perineal care and cleaning of the nares. Also,
making a surgical bed for the client returning from surgery is a basic procedure.
2. Incorrect. The UAP cannot assess or evaluate or even monitor the effectiveness of
pain medication. That is what you are asking the UAP to do here. The client has
received a narcotic and you have asked the UAP to evaluate the effectiveness of the
medication.
5. Incorrect. Administering tube feeding into a PEG tube is beyond the scope of practice
for the UAP. This is a procedure which requires a licensed personnel. Catheter
placement must be confirmed, client identity checked, tube site flushed with water or
sterile water and flow rate determined.
What action should the nurse take after mistakenly administering the wrong medication?
Select all that apply
1. Notify the nursing supervisor.
2. Inform the primary healthcare provider.
3. Complete an incident (variance) report.
4. Document client assessment and response to medication.
5. Document medication error and incident (variance) report in nurse's notes.
1., 2., 3., & 4. Correct: Nurses must immediately report all client care issues, concerns
or problems to the supervising nurse, the primary healthcare provider and/or the
performance improvement or risk management department. A written report of the
incident is completed by the nurse and turned into the appropriate person (generally the
performance improvement department). Documentation of what occurred, and the
client's assessment is required in the nurse's notes.
5. Incorrect: Do not document that an error was made or that an incident (variance)
report was completed. Document what medication was given, the client's assessment,
,the notification of the nursing supervisor, and primary healthcare provider, and any
prescriptions received.
The nurse is caring for four clients. Which client should the nurse see first?
1. The client hospitalized with dehydration related to diarrhea.
2. The seizure client who is currently in the postictal phase.
3. The post-op client who received Morphine 4 mg IV 15 minutes ago.
4. The client who is due pre-op medication now.
3. Correct: This client is at risk for respiratory depression caused by morphine and should
be assessed. Remember airway, breathing and circulation (ABCs). Decreased or
suppressed respiration are priority.
1. Incorrect: Dehydration can produce postural hypotension, fever, confusion,
agitation and if it develops quickly or is severe, coma and seizure may occur.
Decreased respiratory rate would be priority.
2. Incorrect: Postictal is the phase after the seizure where they are drowsy,
lethargic, and possibly asleep. Make sure the client is safe and in the recovery position.
Client would need to be seen soon, but again, decreased respirations takes priority.
4. Incorrect: Decreased or suppressed respirations would be priority over the client
needing pre-op medications.
Following a large hurricane, multiple clients arrive at the emergency room for treatment.
The charge nurse must triage and assign clients to appropriate staff. Which clients
could be assigned to an LPN?
Select all that apply
1. Child with superficial burns on both upper arms.
2. Adolescent with bruising to left upper quadrant.
3. Crying toddler missing both upper front teeth.
4. Adult reporting headache and blurred vision.
5. Elderly adult reporting nausea and heartburn.
1. & 3. Correct: An LPN should be assigned clients with predictable outcomes. Even
though the client is a child, superficial burns require only dry sterile dressings and
possibly oral pain medication, both tasks which are within the scope of practice for an
LPN. The crying toddler has missing front teeth, but there is no indication this was the
result of the hurricane. However, providing care for missing teeth would also be within
the LPN scope of practice.
2. Incorrect: Bruising of the left upper quadrant is often indicative of a ruptured
spleen and internal bleeding. This adolescent will require further tests, such as CT scan,
and possibly emergency surgery. Because of the complexity of the situation, an RN
should be assigned this client.
,4. Incorrect: Since these clients were injured during the hurricane, the charge nurse
must assume the worst. This client is reporting headache and diplopia; therefore, a safe
nurse would consider the possibility of head trauma with brain swelling accounting for
the blurred vision. Such potential makes this client serious to critical, and as such,
should be assigned to an RN for on-going neurologic assessment.
5. Incorrect: While the trauma of a hurricane could adversely affect the digestive
system, the charge nurse would assume the worst and suspect the likelihood the client
is having a myocardial infarction. Only an RN can complete the appropriate
assessment, testing, and other needs expected with an M.I. client.
An LPN/VN has been floated to the emergency room following a chemical plant
explosion. What task would be best to assign to the LPN/LVN?
1. Identify and assess each incoming client.
2. Triage and assign color-coded tags to each client.
3. Gather and apply dressings to open wounds.
4. Initiate oxygen and IV lines as needed.
3. Correct: An LPN/LVN's scope of practice includes tasks such as wound care.
Covering open wounds will help to decrease bacterial exposure until the registered
nurse or primary healthcare provider can assess and treat each wound. If the LPN
notes any serious bleeding situations, it would need reported immediately to the RN.
1. Incorrect: Although it will be crucial to identify each incoming client, the
LPN/LVN's scope of practice does not include assessment. That task would require an
RN or primary healthcare provider.
2. Incorrect: In a mass casualty situation, triage allows the nurse or primary
healthcare provider to quickly determine which clients are critical versus those stable
enough to wait. Because this involves assessment, an LPN/LVN would not be assigned
this task.
4. Incorrect: Initiating intravenous lines is not within the scope of the LPN/LVN.
Additionally, the decision to apply oxygen involves assessment of the respiratory
system, which also is not within the LPN/LVN's scope of practice.
The charge nurse identifies that three admissions were received during the night shift,
one nurse has called in sick, and the clients on the unit have high acuity levels. What
action should the nurse implement first to ensure client safety?
1. Take report on the most critical clients first.
2. Encourage the staff to help each other.
3. Assign one additional client to each nurse.
4. Call the nursing supervisor to request additional staff immediately.
4. Correct: The hospital nurse to client staffing ratio should reflect the complexity of
nursing care for high acuity clients. The nurse should call for immediate help so that a
safe care environment is maintained for all clients. The charge nurse should notify the
, nursing supervisor who will seek additional staff. The nursing supervisor may be able to
assist with client care until another nurse can come in to work.
1. Incorrect: The critical clients are important, but all clients must be considered.
The charge nurse must evaluate each client's status and needs to assign the
appropriate staff to care for them. The safety of each client must be reviewed.
2. Incorrect: The charge nurse may encourage the staff to work together. This is a
positive action but the priority for the charge nurse is to ask for additional staff to
maintain safe nursing care.
3. Incorrect: Each nurse may have to increase his/her client load until adequate
staffing can be obtained. However, calling the nursing supervisor to request help is the
first action.
A nurse working on the pediatric oncology unit is beginning the shift and has received
report which included some new laboratory data for the clients. Based on the
information provided in report, which client condition should be the nurse's priority?
1. Potassium level of 3.4 mEq/L (3.4 mmol/L) in a child with vomiting and diarrhea.
2. Platelet count of 95,000/mm3 in a child with a nose bleed.
3. Absolute neutrophil count of 400/mm3 in a child with fever.
4. Hemoglobin level of 9 g/dL (90 g/L) in a child with reports of fatigue.
3. Correct: The nurse should recognize that this child has a very low absolute neutrophil
count (ANC), which is referred to a neutropenia. This client is at a high risk of infection.
We see that the temperature is already elevated, which makes us worry that infection is
present. Therefore, measures should be instituted to reduce the risk of the development
of an overwhelming infection and sepsis. This client would be the priority based on the
need for prompt recognition and treatment of the neutropenia and signs of infection
present.
1. Incorrect: Although the potassium level of 3.4 mEq/L (3.4 mmol/L) is slightly
decreased, this level can be corrected and should improve when the vomiting and
diarrhea subside. The nurse should continue to monitor the potassium level, but it does
not take priority over the extremely low ANC in the child with fever.
2. Incorrect: This platelet level of 95,000/mm3 is below the normal range of
150,000/mm3 to 400,000/mm3. When the level gets below 100,000/mm3, the clients
should be monitored for bleeding such as a nose bleed, which this client has. However,
nose bleeds are not that uncommon and can often be controlled by applying pressure to
the nares for 5 to 10 minutes. We would not expect to see severe hemorrhage until the
levels are much lower, so this client would not be a priority over the client with the low
ANC with fever.
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