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44 Cards in this Set
- Front
- Back
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The mother of a newborn infant calls a clinic and reports that the umbilical cord is moist and that discharge is present. What should the clinic advise the mother to do?
a) bring the infant to the clinic b) nothing, this is a normal occurrence c) increase the number of times the the cord is cleaned d) monitor the cord for another 24 hours and call the doctor if it persists |
a) bring the infant to the clinic as these are signs of an infection
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What can be expected if there is an Rh incompatibility between mother and fetus?
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Jaundice: Antibodies cross the placenta and destroy RBC resulting in hemolysis and jaundice.
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A 34 week fetus is delivered. The baby is then placed in a radiant warmer. Why is this?
a) the infant has small body surface for her weight b) heat increases the flow of oxygen to the extremities c) her temperature control mechanism is immature d) heat within the isolete facilitates drainage of mucus |
c) her temperature mechanisms are immature
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In assessing the newborn infant, the nurse knows that postterm infants are likely to:
) have heavy vernix, and little lanugo b) be large size for gestational age c) have increased subcutaneous fat and absent creases on the feet d) be small for gestational age |
d) be small for gestational age: Their brown fat stores are used for nourishment as the placenta degenerated
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As the nurse walks into the newborn nursery, she sees a baby in respiratory distress from apparent mucus. The first nursing action is to:
a) carefully slap the infant's back b) thump the chest and start CPR c) pick the baby up by the feet and lower the head d) call the code team |
c) pick the baby up by the feet and lower the head to clear the airway by creating a gravity or postural drainage situation.
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The charge nurse determined that a patient had a low score on the delegation decision making grid. She then decides that:
a) the patient cannot be delegated to someone else b) can be delegated to an LPN or UAP c) more information is needed |
b) can be delegated to an LPN or UAP
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What does a high score on the delegation decision making grid mean?
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This patient should not be delegated to lower level employees.
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What are the 5 rights of delegation?
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Right task
Right direction Right circumstance Right person *Christina Pasay has an STD Right supervision |
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Can the RN delegate reinforcement of what she has already taught?
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Yes
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An RN taught her patient how to use an incentive spirometer. Can she ask the CNA to follow up with the patient and ask him how the new technique is going the next time the CNA is in there taking her vitals?
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No: This is evaluating the patient's response to the care given and this is an RN task.
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Can an RN delegate a CNA to do a cleansing enema?
a) yes b) no c) maybe |
c) maybe: As long as the CNA is competent and has performed this task successfully and comfortably in the recent past.
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Can an LPN perform an initial assessment?
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No
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Can can LPN perform a follow up assessment?
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Yes
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Can an LPN insert a feeding tube or remove sutures?
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Yes
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A RN is going on break and she needs someone to cover her assignment. What is the lowest level of nursing personal that she may ask?
a) an RN b) an LPN c) UAP |
a) an RN
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Nina is an RN in the ICU. She is very busy and is behind in her work. She sees the CNA walking toward her in the hallway and needs to ask her to take vitals on the patient in room 12. How should she ask?
a) Kate, since your not doing anything can you grab a set of vitals for me in 12? b) I'm running really behind, I'm sorry but do you think you can grab a set of vitals in 12 for me? c) Kate, can you please take a set of vitals in room 12. d) Go take 12's vitals and report them back to me Kate. |
c) Kate, can you please take a set of vitals in room 12: Don't assume they are not doing anything; don't apologize: delegating is your professional responsibility; and don't order the CNA around, ask.
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The ability to create fear in others to influence them to change their behavior is commonly termed ___ power.
a) expert b) legitimate c) referent d) coercion e) connection |
d) coercion
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The power that comes from the knowledge and skills that nurses posses is termed ___ power.
a) expert b) legitimate c) referent d) coercion e) connection |
a) expert
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The power derived from the admiration, trust, and respect that people feel toward an individual, group, or organization is termed ___ power.
a) expert b) legitimate c) referent d) coercion e) connection |
c) referent power
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The power that is concerned with the personal and professional relationships is termed ___ power.
a) expert b) legitimate c) referent d) coercion e) connection |
d) connection
*the connection they make with their coworkers |
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The power derived from the position a nurse holds in a group which is derived from their license, academic degree, certification or experience in the role is termed ____ power.
a) expert b) legitimate c) referent d) coercion |
b) legitimate
*the power the person legitimately has based on their credentials |
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What is subordinate power?
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The power for a person to refuse an order if it is outside their scope of practice. For example, if an RN tells the nurse to look at the wound on her patients coccyx while the CNA changes the diaper, and let her know how it looks so she can chart it, the CNA has the right to refuse, as she knows she is not allowed to do assessments.
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The nurse is charting on the patient's I/O record. She charts the following under the output: A large amount of light yellow incontinent urine was voided at 0800 am; no apparent skin breakdown noted. How would you evaluate this charting?
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BAD: "A large amount" is a subjective phrase. What is a large amount? Be specific, a 12 inch circle? A 4 inch circle? A soaked peri pad? Phrases such as "a large amount, a small amount, or a soaked bed" are all subjective, you need to document with objective findings.
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Which of the following topics is the LPN allowed to teach to the patient, CATA:
a) diabetic b) PICC lines c) TPN d) colostomy care e) simple dressing changes f) complex dressing changes g) Central line dressings h) initial colostomy care i) reinforce colostomy care |
a) diabetic
e) simple dressing changes i) reinforce colostomy care |
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Which of the following topics is the UAP allowed to teach about?
a) diabetic b) PICC lines c) TPN d) colostomy care e) simple dressing changes f) complex dressing changes g) Central line dressings h) initial colostomy care i) reinforce colostomy care |
None of the above!!!
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True or False: The LPN and UAP do not practice professional nursing.
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True! Only the RN practices professional nursing.
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Mr. Crowley, age 50 is diagnosed with unstable angina. He has had no chest pain for 24 hours. Who should he be assigned to?
a) an RN b) an LPN c) a CNA |
b) an LPN
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Ms. Sage, a 23 year old diagnosed with bacterial meningitis is on droplet precautions. Who should she be assigned to?
a) an RN b) an LPN c) a CNA |
b) an LPN
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Mr. Shepard, a 64 year old had a heart attack and is on a vent. He has been non-responsive for 1 week. Who should he be assigned to?
a) an RN b) an LPN d) a CNA |
b) an LPN
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True or False: It is ok to delegate a CNA to obtain vitals on a post-op patient who required Narcan for depressed respirations.
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False: While taking vitals can be a task for a CNA, it is only on stable patients that do not require immediate assessment.
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In the 5 rights of delegation, who does the "right person" refer to?
a) the RN doing the delegation b) the client the delegation is concerning c) the person the RN is delegating the task to d) it varies |
c) the person the RN is delegating the task to
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Which right(s) has been violated when an RN delegates a CNA to obtain vitals on a post-op patient who required Narcan for depressed respirations?
a) Right circumstance b) Right person c) Right supervision d) Right task e) Right direction |
a) Right circumstance
b) Right person This task should have been delegated to at least an LPN(right person) since the situation was abnormal(right circumstance). |
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Who would be allowed to assess and document a client's decubitus ulcer?
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An RN
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Who would be allowed to evaluate a client's advance directive status?
a) a CNA b) an LPN c) an RN d) an MD |
c) an RN
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Who would be able to provide written information regarding advance directives?
a) CNA b) LPN c) RN d) CNA, LPN or RN e) LPN or RN |
e) LPN or RN
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Who would be allowed to do the initial feeding of a client who had a stroke and is at risk for aspiration?
a) CNA b) LPN c) RN d) CNA, LPN or RN |
c) RN
*Look out for words such as "initial" "first" "complicated" as they are pointing toward an RN |
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Can an LPN calculate and monitor TPN flow rates?
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No
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Can a CNA total a client's I/O for their 8 hours shift?
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Yes
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Which of the following tasks can be assigned to a CNA? CATA:
a) assisting a client who is experiencing diarrhea with perineal care b) vital signs every 2 hr for a client with pancreatitis c) transportation of a client to the radiology department d) assessing a client for perianal excoriation during perineal care e) cleansing the nares of a client with an NG tube f) reporting the quality and color of a client's NG tube drainage |
a) assisting a client who is experiencing diarrhea with perineal care
b) vital signs every 2 hr for a client with pancreatitis c) transportation of a client to the radiology department e) cleansing the nares of a client with an NG tube |
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A client with bipolar II disorder is yelling at another peer in the milieu. Which nursing intervention takes priority?
a) calmly remove the client from the milieu b) administer prescribed PRN IM injection for agitation c) ask the client to lower his or her voice d) ignore the behavior to de-escalate the aggression |
c) ask the client to lower his or her voice
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A client diagnosed with an eating disorder has recently been admitted to the in-patient psychiatric unit. Which nursing intervention would be appropriate?
a) encourage the client to be independent in self-care activities b) explore family dynamics and the client's role in the family c) allow the client to maintain a dependent role d) explore the client's fear of weight gain |
c) allow the client to maintain a dependent role as trust is developed and the client's physical condition improves, it would be appropriate to encourage client independence.
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A client has a nursing of low self-esteem R/T childhood neglect. Which outcome, based on this diagnosis, would the nurse prioritize? The client will:
a) remain free from injury b) set one realistic goal related to job performance by day 3 c) verbalize one p[positive attribute about self by day 4 d) notify staff if thoughts of suicide occur throughout hospitalization |
c) verbalize one positive attribute about self by day 4: This is the only outcome that relates to the diagnoses
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The nurse is assigned to complete an admission assessment on a client diagnosed with anorexia nervosa. Which of the following assessment data would the nurse expect ot note? CATA:
a) lack of hangar pains b) gross distortion of body image c) preoccupation with food d) refusal to eat e) erosion of teeth enamel |
a) WRONG: Hunger sensations are felt until the food intake is less than 200 calories per day
b) gross distortion of body image c) preoccupation with food d) refusal to eat e) WRONG: This occurs with bulimia |
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Which of the following is true regarding the difference between major depressive disorder and dysthmyic disorder?
a) client with MDD are at higher risk for suicide b) only clients diagnosed with MDD may experience psychotic features c) client with MDD are able to complete ADLs d) to be diagnosed with MDD clients must have symptoms for at least 2 years |
b) only clients diagnosed with MDD may experience psychotic features
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