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Mrs. T is an 80-year-old client admitted to your nursing unit with a diagnosis of weakness, status post fall. The admission face sheet indicates that she is widowed and lives alone. As you work through your nursing admission assessment, which of the following would be the least priority concern?
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Ask Mrs. T about the details of her fall.
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Does Mrs. T like to read?
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Ask Mrs. T about her ability to shop and cook for herself.
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What medications has she been taking?
(2) Mrs. T's reason for admission is weakness and a fall. Priority concerns in assessment would be to identify any intrinsic or extrinsic factors that lead to her fall. Her interest in reading, although it be important in determining possible activities to incorporate into her care plan while in the hospital, is a lesser priority.
In communicating a delegated task to a nursing assistant (UAP), an example of optimal direction is:
"Let me know if you see any signs of a heart attack."
"Please offer the patient the bedpan every two hours on the even hours. Let me know the total urine output at 2:00 p.m."
"Let me know whether anything happens with this confused patient. "
"Keep an eye on this hallway while I'm at lunch."
(2) When delegating, the use of specific, behavioral directions will be most likely to obtain desired results.
All of the following tasks may be delegated to the LPN except:
developing a patient teaching plan regarding the patient's diet, exercise, and medications.
monitoring Mrs. B's blood sugars via accucheck.
performing dressing changes in the infected foot.
administering the patient's pain medication.
(1) Developing a patient teaching plan is a professional nursing function that is in the scope of RN responsibilities. RN's may delegate specific teaching activities to an LPN in order to execute the plan using the same five rights of delegation. Accuchecks, dressing changes, and medication administration are tasks within the role of the LPN (in most states).
On the third day during which you are caring for Mrs. B., she complains of chills. Checking her temperature, the nursing assistant comes to you and reports that it is 101.8.
As you assess Mrs. B., you discover that her wound looks more inflamed, feels hot to touch, and is oozing some yellow/green drainage. The patient tells you that it's been like that the last two days. Checking the chart, you see that the LPN who had done the dressing changes documented a similar appearance two days ago. Who is responsible?
the nursing assistant who checked her temperature.
the LPN who did the dressing changes.
you are, as the RN.
you, as the RN, and the LPN.
(4) Both the RN and the LPN are responsible in this situation. The LPN who performed the dressing changes did not recognize signs of infection, and/or if she did, she failed to bring them to the attention of the RN. As the RN, you are also responsible for the care that you delegated to this LPN. The RN retains responsibility for tasks that are delegated and must perform necessary supervision.
Referral to a home care agency requires:
a physician's order.
a client need for skilled nursing or therapy.
consent of the client.
all of the above.
(4) Home care referral requires a consenting client, a client with a skilled nursing or therapy need, and a written order by a physician.
Informed consent involves all the following requirements except:
The client must be capable of making decisions.
When informed consent is given, it cannot be revoked.
The decision must be made voluntarily without coercion.
The client must understand the potential risks and benefits that might result from consenting to a procedure.
(2) Informed consent can be revoked by the client at any time. Choices 1, 3, and 4 are requirements of informed consent.
Which statement is incorrect regarding obtaining informed consent from a client for a nursing research study?
An individual participating in a study must give informed consent to participate in the study.
Informed consent for nursing research occurs after the study begins and can occur any time before study completion.
Obtaining informed consent is the responsibility of the principal investigator.
Informed consent must be documented in writing.
(2) Informed consent for participation in research must occur prior to the initiation of the study or research activity involving a client. Choices 1, 3, and 4 are true and therefore incorrect as the answer. Informed consent is required for research participation. The principal investigator is responsible for obtaining consent from study subjects, and that consent must be documented in writing.
A post-myocardial infarction client has an order for cardiac rehabilitation. When discussing this order with the client, the client responds, "I thought rehab was only for people who had stokes." The nurse should explain that:
rehab involves only physical and occupational therapy.
any service outside an acute care hospital is termed rehab.
rehab is just a term used by insurance companies for post-hospital care.
rehab is any long-term care service for additional therapy or treatment to assist a client in recovery from an illness or injury.
(4) Rehabilitation involves many professional disciplines including nursing, physical therapy, medicine, occupational therapy, speech therapy, social work, and others. Rehabilitation services are provided as part of an organized plan to assist a client in recovering from an illness or injury. Rehabilitation services can be delivered in a long-term care facility, through a home care agency, or in an outpatient care setting.
A newly diagnosed 68-year-old diabetic client is being discharged from the hospital. The home care referral can include all the following services except:
a nutritional consult for diet education and follow-up.
a podiatry consult for foot care.
a nursing consult for glycemic monitoring instruction.
all of the above.
(2) Foot care for diabetics is an important issue, but the podiatrist is not usually a member of the home care agency team. A nurse and a dietician should be on the home care agency team
A 14-year-old first-time mother is going home from the hospital with her newborn. An appropriate referral for support of this mother-infant dyad might be:
a home care agency with maternal-infant services.
an adoption agency.
Planned Parenthood.
a nurse midwife.
(1) Referral to a home care agency with maternal-infant services for education and initiation of community services is the best choice. A nurse midwife might be appropriate prior to delivery, but does not initiate care in the postpartum period. An adoption agency is only a referral choice if the mother is giving the child up for adoption. Referral to Planned Parenthood for family-planning services for a minor child necessitates consent of a parent or guardian.
At 11:00 a.m. a client is brought to the unit from the Emergency Department for admission. Lying on the transport cart, the client complains of severe nausea and vomits into an emesis basis. The client's family is with him. Which action is the most appropriate for the nurse to take at this time?
Help get the client into bed and orient him to the bed controls.
Help get the client into bed and begin to fill out the detailed admission assessment form.
Ask the client whether he has valuables for the safe.
Help get the client into bed, properly positioned for comfort, and begin focused abdominal assessment targeting his nausea.
(4) Although the process for admission is an important one, in this instance the priority for the nurse becomes intervening on behalf of the client's comfort. After the symptoms are alleviated, the client can participate in the admission process.
A client comes to the nurses' station asking to read her chart. The nurse's best response is:
to supply the chart and answer any questions.
to ask the client to wait until the doctor comes.
to call the doctor for permission.
to ask the client why she wants to read the chart, write down the reasons, and any questions the client has and pass them along to the nursing supervisor.
(1) A client legally owns her medical record and should have access to it. Because the client might not understand some of the material contained within the chart, a professional should be available to explain and interpret. The physician should be notified as a courtesy so that he or she can arrange to participate in the chart review with the client; however, the physician does not need to give permission for the chart review. Note: The client must have access to and/or copies of the medical record on request, but the original documents are the property of the facility.
A 35-year-old female patient on your hospital unit is awaiting a liver transplant. All the following statements about organ donations are true except:
More than 85% of adult Americans approve of organ donation.
Organ recipients are matched to donors by age and sex.
More than 17,000 people were awaiting liver transplants in 2004.
Less than 6,000 liver transplants were performed in 2003.
(2) Organ recipients and donors are matched for tissue types and organs needed, but not by age and sex. It is true that more than 85% of adult Americans approve of organ donation. In 2003, 25,640 persons received organ transplants; liver transplants accounted for 5,671 of these. In 2004, more than 17,000 people were awaiting liver transplants.
You are the emergency nurse on duty when a young man is brought in after an auto accident with massive head injuries. You know that if he is judged to be brain dead, organ donation is suggested. Which of the following statement is true about organ donation?
The family of a donor is not charged for the cost of organ donation.
Organ donation disfigures the donor and potentially alters the funeral arrangements.
The family is not asked for organ donation when a client has massive head injuries.
The donor's name and personal information is given to the organ recipient to facilitate communications after the transplant.
(1) The family or donor's estate is not charged for organ donation. Organ donation does not disfigure the donor. Funeral arrangements, such as open caskets, do not have to be altered because of donation. Often families of clients with massive head injuries who become brain dead are given the opportunity to donate organs because the other organs are still functional. The donor's information is confidential and not communicated to the recipient under normal circumstances.
