Practice Questions
You are currently conducting a class regarding the nursing model of practice implemented in the health care facility. You know that the student nurse has achieved the objectives of the class when she determines which scenario is characteristic of the team-based model of nursing practice?
- Each staff member is assigned a specific task for a group of clients.
- A staff member is assigned to determine the client’s needs at home and begin discharge planning.
- A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an assistive personnel (AP).
- An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients.
Rationalization
Nurse Gary is the head nurse of a medical ward. He is currently planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)?
- A client requiring a colostomy irrigation
- A client receiving continuous tube feedings
- A client who requires urine specimen collections
- A client with difficulty swallowing food and fluids
Rationalization
Nurse Jumela is a nurse in a hospice care center. She is planning assignments for the clients. She needs to assign four clients and has a licensed practical nurse and 2 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse?
- A client who requires a bed bath
- An older client requiring frequent ambulation
- A client who requires hourly vital sign measurements
- A client requiring abdominal wound irrigations and dressing changes every 3 hours
Rationalization
Nurse Arnel is the charge nurse for the day shift. He is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply.
- The acuity level of the clients
- Specific requests from the staff
- The clustering of the rooms on the unit
- The number of doctors that shall make rounds
Rationalization
The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands?
- Every 2 hours
- Every 3 hours
- Every 4 hours
- Every 30 minutes
Rationalization
Nurse Carrie is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply.
- The nurse who never had roseola
- The nurse who never had mumps
- The nurse who never had chickenpox
- The nurse who never had German measles
Rationalization
When creating an assignment for a team consisting of a registered nurse (RN), 1 licensed practical nurse (LPN), and 2 assistive personnel (AP), which is the best client for the LPN?
- A client requiring frequent temperature checks
- A client requiring assistance with ambulation every 4 hours
- A client on a mechanical ventilator requiring frequent assessment and suctioning
- A client with a spinal cord injury requiring urinary catheterization every 6 hours
Rationalization
Nurse Sammy is caring for a client with focal crescentic glomerulonephritis. The nurse instructs the assistive personnel (AP) to implement which action when caring for the client?
- Ambulate the client frequently.
- Encourage a diet that is high in protein.
- Remove the water pitcher from the bedside.
- Monitor the client’s temperature every 2 hours. Routine tasks can be delegated.
Rationalization
Nurse Rebecca hears a client calling out for help, hurries down the hallway to the client’s room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report?
- The client fell out of bed.
- The client climbed over the side rails.
- The client was found lying on the floor.
- The client became restless and tried to get out of bed.
Rationalization
A female elderly was hit by a car while crossing the street. Her name is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. The EMS brought her to the ER. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?
- Obtain a court order for the surgical procedure.
- Ask the EMS team to sign the informed consent.
- Transport the victim to the operating room for surgery.
- Call the police to identify the client and locate the family.
Rationalization
Nurse Florita is originally a pediatric nurse. Today is her first day as a floater at the surgery ICU. The nurse should take which best action?
- Refuse to work to the ICU based on lack of unit orientation.
- Clarify the ICU client assignment with the team leader
- Ask the nursing supervisor to review the hospital policy on floating.
- Submit a written protest to nursing administration, and then call the hospital lawyer.
Rationalization
Nurse Allen works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?
- Call security.
- Call the police.
- Call the nursing supervisor.
- Lock the coworker in the medication room until help is obtained.
Rationalization
Lory, a 75 year old, told the nurse that her lawyer shall send the papers for her last will. She asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?
- “I will sign as a witness to your signature.”
- “You will need to find a witness on your own.”
- “Whoever is available at the time will sign as a witness for you.”
- “I will call the nursing supervisor to seek assistance regarding your request.”
Rationalization
Nurse Romina delivers a lecture to nursing students regarding the issue of clients’ rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?
- Performing a procedure without consent
- Threatening to give a client a medication
- Telling the client that he or she cannot leave the hospital
- Observing care provided to the client without the client’s permission
Rationalization
Nurse Marina is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?
- Sara Lee, 45/F, postoperative client preparing for discharge with a new medication
- Andrew Kim 25/M, requiring daily dressing changes of a recent surgical incision
- Hannah Park, scheduled for a chest x-ray after insertion of a nasogastric tube
- Joel Kim, diagnosed with asthma who requested a breathing treatment during the previous shift
Rationalization