1
Which statements are true regarding delegation of duties to unlicensed assistive personnel (UAPs) by a licensed nurse? (Select all that apply.)
a. The LPN/LVN in charge must be familiar with the competency of staff.
b. The LPN/LVN must be familiar with the job descriptions of UAPs.
c. An LPN/LVN may delegate any skill or task to a UAP once the nursing assistant has demonstrated proficiency.
d. A nurse must be familiar with the nurse practice act.
e. The certification of the UAP makes nursing assistants liable for their actions.
ABD
Delegation requires that the LPN/LVN be familiar with the competency of the staff as well as their job description. Even if the nursing assistant is proficient in a skill, no delegation requiring clinical judgment is allowed. The nursing assistant is not liable; the supervising nurse is.
Conclusions that have been made based on observed data are __________.
inferences
Inferences are conclusions made based on observed data.
The nurse using protective nonsterile gloves in the provision of patient care will wash his or her hands after removal of the gloves in order to:
a. avoid transfer of organisms.
b. diminish possibility of latex allergy.
c. keep skin of hands from cracking and drying.
d. enhance the ease of donning a fresh pair of gloves
A
Washing the hands immediately after removing barrier gloves decreases the likelihood that organisms will gain access to the skin through small holes or imperfections in the gloves and reduces the transfer of microorganisms to the environment and other persons.
The nurse taking an apical pulse would place the stethoscope at:
a. the left of the sternum at the third intercostal space.
b. directly below the sternum.
c. slightly above the left nipple.
d. the left midclavicular line at the fifth intercostal space.
D
The apical pulse is determined by placing a stethoscope on a point midway between the imaginary line running from the midclavicle through the left nipple in the fifth intercostal space.
ent requires suctioning via the nasotracheal route. In order to perform this procedure safely, the nurse should:
a. apply suction while advancing the catheter into the airway.
b. suction the nasotracheal passage after suctioning the mouth.
c. hold the catheter with the dominant hand after donning sterile gloves.
d. insert the nonlubricated catheter into the nasal passage.
C
The suction catheter should be held with the dominant hand after donning sterile gloves, because sterile technique must be adhered to when suctioning both the nasopharyngeal and tracheal areas.
Important characteristics of delegation to an unlicensed assistive personnel (UAP) include: (Select all that apply.)
a. use of effective communication.
b. provision of constructive criticism immediately.
c. direction for the desired result and time for completion.
d. provision of tactful feedback.
e. informing the patient that the delegated task will be performed by a UAP.
ACDE
When delegating to UAPs, it is important to use effective communication, as well as direction for results. Patients should be informed that the task will be performed by a UAP. Constructive criticism should be done privately after the event and should always be done tactfully.
Staff nurses have many responsibilities to their patients throughout their shift. However, the ______ is responsible for the total nursing care of patients during a shift and is also responsible for giving handoff reports to the oncoming shift and evaluating members of the health care team.
charge nurse
All nurses need to know the responsibilities of each person on the health care team, and the charge nurse is responsible for the total nursing care of patients during a shift.
A patient is sent home with an open wound that is still infected and being treated with wet-to-dry dressing changes four times a day. Before discharge, in order to prevent infecting other family members, the nurse would teach the patient to:
a. be the only person to perform the dressing changes, thus eliminating the risk of infection to other family members.
b. wash hands thoroughly before the dressing change.
c. use gowns, gloves, and masks for any family contact with him.
d. maintain medical asepsis and proper handling of the contaminated dressings.
D
Medical asepsis is the most important way of preventing the spread of infection in the home or in the hospital or nursing home.
The nurse lightly palpates the abdomen of a patient during a physical examination. On palpation to the right side of the abdomen, the patient cries out and draws the knees to the chest. The nurse should:
a. discontinue the examination and report findings to the primary care provider.
b. palpate the abdominal skin 1.5 to 2 inches to determine the cause of pain.
c. continue the examination and have the patient take deep breaths.
d. proceed to percuss the abdomen with a quick snap of the wrist.
A
When palpating, the nurse should observe the patient’s face for signs of discomfort and discontinue palpations if they appear to cause pain.
The nurse outlines characteristics that affect the virulence of microorganisms, which include: (Select all that apply.)
a. sensitivity to heat.
b. adherence to mucosal surfaces.
c. secretion of enzymes.
d. secretion of toxins.
e. penetration of mucous membranes.
BDE
The virulence of a microorganism is affected by the ability to adhere to and penetrate mucosal membranes, multiply in the body, secrete harmful toxins, resist phagocytosis, and bind with iron.
Which responsibilities are common to an LPN/LVN team leader in both health care facilities and medical clinics? (Select all that apply.)
a. Organizes staff meetings.
b. Assists in writing policies and procedures.
c. Assists in resolving staff conflicts.
d. Prepares the schedule for patient activities.
e. Evaluates unlicensed assistive personnel (UAPs).
BCE
Writing policies and procedures, assisting to resolve staff conflicts, and evaluating UAPs are duties common to LPN/LVN team leaders in health care facilities. Only in medical clinics do LPNs/LVNs generally attend staff meetings and oversee scheduling of patients.
When a patient chooses to die by refusing treatment that would prolong life, it is called ___________.
passive euthanasia
Passive euthanasia is when the patient is choosing to refuse treatment for himself or herself, which will result in death.
The nurse clarifies that the difference between the use of earlier types of isolation procedures and the use of current Standard Procedures plus Transmission-Based Precautions as outlined by the CDC:
a. is that new diseases have continued to appear for which the older isolation techniques were ineffective.
b. is based on the premise in the new procedures that all body substances except sweat may be infectious, even when the person is not known to have a specific disease.
c. is complicated and hard to follow.
d. is based on newer knowledge of how HIV is spread, to better protect health care workers from blood-borne pathogens.
B
Earlier Universal Precautions and Isolation Precautions focused on preventing the spread of blood-borne pathogens and secretions or excretions of a person specifically known to be infected. They have been replaced with Standard Precautions for all patients, and Transmission-Based Precautions for those specifically infected, because of the understanding that infection may be present in body secretions or excretions even when the person is apparently healthy
A nurse records absence of bowel sounds after assessing the abdomen:
a. in the two lower quadrants for 2 minutes each.
b. in the two upper quadrants for 5 minutes.
c. in all quadrants for 3 minutes each.
d. in each quadrant for 1 minute.
C
Auscultate for bowel sounds with the patient in a supine position. An absence of bowel sounds should be documented after there are no bowel sounds in each quadrant for 2 to 5 minutes.
Differences between Airborne and Droplet Precautions include which of the following? (Select all that apply.)
a. A surgical mask must be worn with Airborne Precautions.
b. Patients on Droplet Precautions do not need to wear a surgical mask when outside their rooms.
c. A surgical mask must be worn if working within 3 feet of a patient on Droplet Precautions.
d. Airborne Precautions include placing the patient in a negative pressure room.
e. A specialized respirator mask must be worn with patients on Droplet Precautions.
f. Standard Precautions need to be used only with patients on Airborne Precautions.
CDE
The Centers for Disease Control and Prevention (CDC) recommends the use of specialized respirator masks when working with patients on Airborne Precautions and a surgical mask when working within 3 feet of a patient on Droplet Precautions. Both Airborne and Droplet Precautions include the use of a private room; however, a negative pressure room is required for Airborne Precautions. Standard Precautions are to be used with all patients.
During the dying process, patients may experience a bad taste in their mouth. Which of the following are appropriate nursing actions? (Select all that apply.)
a. Offer the patient hard candy.
b. Assist the patient with frequent oral care.
c. Offer the patient large amounts of water or juice.
d. Explain to the patient that this is a normal part of dying and nothing can be done.
e. Offer the patient mouthwash.
f. Offer the patient frequent meals.
ABE
Hard candy, mouthwash, and oral care help stimulate saliva production and relieve the dryness and any bad taste in the patient’s mouth related to the dryness.
The patient inquires about how his body will kill pathogens unassisted by antibiotics. The nurse responds that a process called phagocytosis will:
a. stimulate the body to make more white blood cells.
b. create antibodies against the pathogen.
c. engulf and destroy the pathogen.
d. stimulate the production of interferons.
C
Phagocytes that are stored in the GI tract, liver, and spleen kill pathogens by engulfing and destroying the invaders and cleaning up the debris.
The nurse adding sterile liquids to a sterile field should:
a. hold the liquid container high over the sterile field.
b. remove the cap and place the container with the inside facing down.
c. prepare a new sterile field if it becomes wet during the procedure.
d. carefully reach over the sterile field to pour the liquid.
C
Once a sterile field is wet, it is contaminated, and a new field needs to be prepared.
The nurse is comparing sitting and standing vital signs for a patient who has been diagnosed with dehydration. The pulse rate has increased by 10 beats/min at 1 minute. The nurse then anticipates the blood pressure to show a(n):
a. increase of 5 mm Hg.
b. drop of 40 mm Hg.
c. drop of 20 mm Hg.
d. increase of 10 mm Hg.
C
A drop in systolic blood pressure by at least 20 mm Hg accompanied by a pulse rate increase of at least 10 beats/min at 1 minute following position change is suggestive of fluid volume deficit.
A nurse is caring for a patient in protective isolation for extreme immunosuppression. Before entering the room, which of the following actions should the nurse take? (Select all that apply.)
a. Don a gown.
b. Don a mask.
c. Put on gloves.
d. Apply a head covering.
e. Apply shoe coverings.
f. Bring in the blood pressure cuff and stethoscope.
ABC
A gown, mask, and gloves are all that is required; however, the CDC or hospital policies may require full PPE protection.
A coroner is required to investigate death in which of the following situations? (Select all that apply.)
a. Deaths from injury
b. All deaths that occur at home
c. Suspected suicides
d. Any death in the hospital
e. Deaths of persons not under the care of a primary care provider
ACE
The coroner investigates death when there may be a question of cause.
An organism that is included in the extended-spectrum beta-lactamase–producing pneumonia (ESBL) group is:
a. Staphylococcus aureus.
b. Clostridium difficile.
c. Enterococcus.
d. Escherichia coli.
D
E. coli and Klebsiella pneumoniae are the organisms in the ESBL group.
The nurse would anticipate a patient diagnosed with damage to the hypothalamus after suffering a head injury from a fall to exhibit:
a. a blood pressure elevation.
b. a temperature abnormality.
c. a decrease in pulse rate.
d. depressed respirations.
B
The hypothalamus, which is located between the cerebral hemispheres, controls body temperature. Any damage to the hypothalamus prevents the body from regulating its temperature.
A patient who will begin oxygen therapy has a history of sinus disorders. This patient would benefit most from which oxygen setup?
a. High oxygen flow rate
b. A humidifier
c. A Venturi mask
d. A nasal cannula
B
If a patient suffers from sinus problems, it is best to add a humidifier to the oxygen setup.
The nurse clarifies that the duties of the facility’s infection preventionist include: (Select all that apply.)
a. viewing every culture that is performed in the facility that is positive for pathogens.
b. investigating possible causes for the occurrence of health care–associated infections (HAIs).
c. sanitizing isolation rooms after patients have been discharged.
d. counseling persons who have been found to be careless about infection control protocols.
e. providing education to health care staff relative to infection control.
ABDE
The infection preventionist (IP) follows up on all positive cultures, investigates possible causes of HAIs, and provides ongoing education to staff. Counseling and sanitizing are not directly the responsibility of the IP, although he or she might suggest counseling and supervise sanitizing procedures.