REVISION QUESTIONS AND

Safe and effective care environment management of care COMPLETE

REVISION QUESTIONS AND

CORRECT DETAILED ANSWERS

(VERIFIED ANSWERS) ALREADY

GRADED A+

The nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which client task should the nurse delegate to the UAP?

• a client whose IV infiltrated and needs replacing
• a client on BiPAP who needs arterial blood gases (ABGs) drawn
• a client with mild dementia who needs assistance with her food tray
• a client who needs a wet-to-dry dressing change on an abdominal incision - Answer: number 3 is

correct Assessing the IV site and inserting an IV is beyond the scope of practice for a UAP and should be performed only by the licensed nurse. Drawing ABG's should be performed by the licensed nurse or respiratory therapist per facility policy. Assisting a client with a meal tray is within the scope of practice for a UAP. Dressing changes should be performed by the licensed nurse. UAPs may not provide direct nursing care or perform nursing interventions requiring specialized nursing knowledge, judgement or skill.A nurse is preparing a client scheduled for a right mastectomy. Which statement indicates the need for further intervention?

• The client refuses to sign the blood consent since she is a Jehovah's witness
• The client identifies the right breast as the surgical site for a right mastectomy.
• The client signs the consent form with an X, which is witnessed by two licensed personnel
• The client expresses doubt over her decision and asks the nurse to explain more about the procedure.

- Answer: Number 4 is correct.

Expressing doubt and asking further questions about the procedure to the nurse indicates that the client may not be fully informed and should confer further with the health care provider. The nurse may clarify facts, but it is the health care provider's responsibility to give detailed information about a surgical procedure. The nurse is responsible for ensuring the client has been adequately informed. A client may 1 / 2

refuse to sign a blood consent due to religious beliefs prior to surgery. The client has correctly identified the surgical site, which is to be expected. The client who cannot write may sign with an x as long as it is witnessed by two people.An external weather disaster has flooded the emergency department with several new clients. Which client should the nurse see first?

• The client complaining of chest pain and nausea who is diaphoretic
• the client with a simple fracture of the radius from a fall on a staircase
• the client complaining of slight redness and itching at the IV site in his hand
• the client presenting with a sprained ankle from a tree branch failing on him - Answer: Number 1 is

correct Triage works on the principle that clients with the highest acuity have priority over clients with injuries or conditions that are not considered life-threatening. Chest pain, nausea and diaphoresis indicate a possible myocardial infarction, which can be life- threatening and requires immediate intervention.Fractured and sprains are non-urgent and can wait for treatment. Redness and itching at an IV site indicates a need to asses the site and remove and replace the IV, but is not immediately life- threatening.A nurse is working with an unlicensed assistive personnel (UAP) to perform a bed bath on a client. The nurse notes the smell of alcohol on the UAP's breath. Which is the priority nursing action?

• Work closely with the UAP during the shift and observe for any signs of impairment.
• Complete the bed bath without comment. The unit is already short one staff member.
• Offer chewing gum to the UAP. Since she does not give medications, she can do her job as she does

not appear impaired

• Call for another nurse to complete the bath and immediately report the UAP to the charge nurse or

unit manager. - Answer: number 4 is correct

The professional nurse works under the framework of six ethical principles. Nonmaleficence emphasizes protecting the client from harm. Client safety is always a priority. Another nurse may step in and complete the bath, ensuring that the client is not left alone with impaired personnel. Options 1, 2 and 3 allow the impaired UAP to remain on duty, possibly causing harm to the client. The nurse also has an ethical and legal duty to report situations that may cause client danger. Failure to do so may result in disciplinary action by the board of nursing for the nurse involved, regardless of whether harm comes to the client.The nurse has received report on the assigned night-shift clients. Which client should the nurse see first?

• / 2