QUESTIONS AND ANSWERS WITH
RATIONALES.
Can an RN delegate to the LPN to provide tracheostomy
care to a client with pneumonia? - ANSWER-Yes.
A nurse on a med-surg unit has received change-of-shift
report & will care for 4 clients. Which of the following
client's needs may the nurse assign to an assistive
personnel (AP)?
A. Feeding a client who was admitted 24 hrs ago
w/aspiration pneumonia
B. Reinforcing teaching w/a client who is learning to walk
using a quad cane
C. Reapplying a condom catheter for a client who has
urinary incontinence
D. Applying a sterile dressing to a pressure ulcer -
ANSWER-C. Reapplying a condom catheter for a client
who has urinary incontinence
,Rationale: The application of a condom catheter is a
noninvasive, routine procedure that the nurse may
delegate to the AP
A nurse is delegating the ambulation of a client who had
knee arthroplasty 5 days ago to an AP. Which of the
following information should the nurse share with the
AP? Select All.
A. The roommate is up independently.
B. The client ambulates w/his slippers on over his
antiembolic stockings
C. The client uses a front-wheeled walker when
ambulating
D. The client had pain medication 30 min ago
E. The client is allergic to codeine
F. The client ate 50% of his breakfast this morning -
ANSWER-B, C, D
An RN is making assignments for client care to a LPN at
the beginning of the shift. Which of the following
assignments should the LPN question?
A. Assisting a client who is 24hr 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 -
ANSWER-D. Replacing the cartridge and tubing on a
PCA pump
Rationale: The RN is responsible for the PCA pump
A nurse is preparing an in-service 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 - ANSWER-B, C, E
A and D are rights of medication administration
A nurse manager of a med-surg unit is assigning care
responsibilities for the oncoming shift. A client is
awaiting transfer back to the unit from the PACU
following thoracic surgery. To which staff member should
the nurse assign to this client?
A. Charge nurse
, B. RN
C. LPN
D. AP - ANSWER-B. RN
A client returning from surgery requires assessment and
establishment of a plan of care. RNs are responsible for
this, especially if the client is potentially unstable.
A nurse observes an AP reprimanding a client for not
using the urinal properly. The AP tells him she will put a
diaper on him if he does not use the urinal more carefully
next time. Which of the following torts is the AP
committing?
A. Assault
B. Battery
C. False imprisonment
D. Invasion of privacy - ANSWER-A. Assault
By threatening the client, the AP is committing assault.
An adult client who is competent tells the nurse that he is
thinking about leaving the hospital against medical
advice. The nurse believes that this is not in the client's
best interest, so she administers a PRN sedative med that
the client has not requested along w/his usual meds.
Which of the following tort has the nurse committed?