Answers Edition
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
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
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
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
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
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
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?
A. Assault
B. False imprisonment
C. Negligence
D. Breach of confidentiality
, The nurse gave the med as a chemical restraint to keep the client from
leaving the facility against medical advice. The client did not consent.
A client who will undergo neurosurgery the following week tells the
nurse in the surgeon's office that he will prepare his advance directives
before he goes to the hospital. Which of the following statements by
the client indicates to the nurse that he understands advance
directives?
A. "I'd rather have my brother make decisions for me, but I know it has
to be my wife."
B. "I know they won't go ahead w/the surgery unless I prepare these
forms."
C. "I plan to write that I don't want them to keep me on a
breathing machine."
D. "I will get my regular doctor to approve my plan before I hand it in
at the hospital."
The client has the right to decide and specify which medical
procedures he wants when a life-threatening situation arrives
A client is about to undergo an elective surgical procedure.
Which of the following actions are appropriate for the nurse
who is providing preop care regarding informed consent?
Select all.
A. Make sure the surgeon obtained the client's consent
B. Witness the client's signature on the consent form
C. Explain the risks and benefits of the procedure
D. Describe the consequences of choosing not to have the surgery
E. Tell the client about alternatives to having the surgery
The rest of the choices are the surgeon's responsibility, not the nurse
A nurse has noticed several occasions in the past week when
another nurse on the unit seemed drowsy & unable to focus on
the issue at hand. Today, she found the nurse asleep in a chair
in the break room when she was not on break. Which of the
following actions should the nurse take?
A. Remind the nurse that safe client care is a priority on the unit
B. Ask others on the team whether they have observed the same