NUR 112/ NURSING FUNDAMENTAL 2022

What can be delegated to Assistive personnel (AP)? (Ans)- - ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow precautions) - positioning - bed making - specimen collection - I&O - VS (stable clients A nurse on a med surge unit has recieved change of shift report and will care for 4 clients. Which of the following clients needs will the nurse assign to an AP? A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia B. Reinforcing teaching with a client who is learning to walk with a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer (Ans)- C A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP? Select all: A. the roommate is up independently B. The client ambulates with his slippers on over his antiembolic stockings C. The client uses a front wheeled walker when ambulating D. The client had pain meds 30 minutes ago E. The client is allergic to codeine F. the client ate 50 % of his breakfast this morning (Ans)- B C D An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question? A. Assisting a client who is 24 hr postop to use an incentive spirometer B. Collecting a clean catch urine specimen from a client who was admitted on the previous shift C. providing nasopharyngeal suctioning for a client who has pneumonia D. Replacing the cartridge and tubing on a PCA pump (Ans)- D A nurse is preparing an inservice program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation. Select all: A. Right client B. Right supervision/evaluation C. Right direction/communication D. Right time E. Right circumstances (Ans)- B C E A nurse manager of a med surge unit is assigning care responsibilities for the oncoming shift. A client is waiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign the client? A. Charge nurse B. RN C. LVN D. AP (Ans)- B What is the study of conduct and character? (Ans)- Ethics What are the values and beliefs that guide behavior and decision making? (Ans)- Morals What is the right to make ones own personal decisions, even tho those decisions might not be in the persons best interest (Ans)- Autonomy What are positive actions to help others (Ans)- Beneficience What is an agreement to keep promises (Ans)- Fidelity What is fairness in care delivery and use of resources (Ans)- Justice What is avoidance of harm or injury (Ans)- Non-maleficence A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of what principles? A. Fidelity B. Autonomy C. Justice D. Nonmalificience (Ans)- A A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficience (Ans)- D A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which ethical principle A. Fidelity B. Autonomy C. Justice D. Nonmaleficence (Ans)- C A nurse questions a med prescription as too extreme and light of the clients advanced age and unstable status. The nurse understands that this action is an example of which ethical principle A. Fidelity B. Autonomy C. Justice D. Nonmalificence (Ans)- D Which of the following situations can be identified as an ethical dilemma? A. A nurse on a med surge unit demonstrates signs of chemical impairment B. A nurse over hears another nurse telling an older adult client that if he doesnt stay in bed she will restrain him C. A family has conflicting feelings about the initiation of enteral tube feedings of their father who is terminally ill D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form (Ans)- C Most managers can be categorized as (Ans)- authoritative, democratic, and laissez faire makes decisions of the group motivates by coercion communication occurs down the chain of command Work output by the staff is usually high-good for crisis situations and bureaucratic settings (Ans)- Authoritative includes the group when decisions are made Motivates by supporting star achievements Communication occurs up and down the chain of command Work output by staff is usually of good quality-good when cooperation and collaboration is necessary (Ans)- Democratic makes very few decisions and does little planning motivation is largely the responsibility of individuals staff members Communication occurs up and down the chain of command and between group members Work output is low unless an informal leader evolves from the group *the use of any of these styles may be appropriate depending on the situation (Ans)- Laissez faire The nurse should consider the hierarchy of human needs when prioritizing interventions, which are? (Ans)- - Physiological needs first (oxygen, shelter, food) - Safety & security needs (physical safety) - Love and belonging - Self esteem - Self actualization The ABC framework identifies, in order, the three basic needs for sustaining life (Ans)- Airway Breathing Circulation Nurses must follow what code of standards in delegating and assigning tasks (Ans)- ANA codes of standards What values would a nurse possess to be a client advocate? (Ans)- - caring - autonomy - respect - empowerment What do the nurse need to keep in mind about the client when being their advocate? (Ans)- Client's religion & culture When should planning discharge process begin? a. at time of admission b. 2 days after client is admitted c. whenever the nurse has the time to do planning d. when the physician has the discharge order (Ans)- A What is an interdisciplinary team? (Ans)- A group of health care professionals from different disciplines Fill in the blank: 1. _______ is used by interdisciplinary team to make health care decisions about clients with multiple problems. 2. ________, which may take place at team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone. (Ans)- 1 & 2 = collaboration What is the nurse's contribution to an interdisciplinary team? (Ans)- - knowledge of nursing care & its management - a holistic understanding of the client, her/his healthcare needs & healthcare systems. A four-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding would indicate an increase in intracranial pressure? 1. Positive Babinski. 2. High-pitched cry. 3. Bulging posterior fontanelle. 4. Pinpoint pupils. (Ans)- 2