safe and effective care/disaster: cultural diversity, ethical/legal delegation & disaster issues...
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Safe and Effective Safe and Effective Care/Disaster: Cultural Care/Disaster: Cultural Diversity, Ethical/Legal Diversity, Ethical/Legal
Delegation & Disaster Issues Delegation & Disaster Issues in Nursingin Nursing
Created by Professor Jill RayCreated by Professor Jill RayRevised by Professor Brenda RoweRevised by Professor Brenda Rowe
What tasks can an RN What tasks can an RN Delegate?Delegate?
Who is she delegating the task to?Who is she delegating the task to? What type education/experience does What type education/experience does
that individual have?that individual have? Is there something about the task that Is there something about the task that
requires the skill/knowledge of an RN?requires the skill/knowledge of an RN? Is there something about the task that Is there something about the task that
requires the skill/knowledge of a requires the skill/knowledge of a specialized RN?specialized RN?
The person to whom the The person to whom the task is delegated must have task is delegated must have
the education and the the education and the experience required to experience required to
complete the task safely complete the task safely and effectively.and effectively.
When would a task be When would a task be considered routine…considered routine…
when should a when should a “routine” task be “routine” task be completed by an RN?completed by an RN?
1. The nursing team consists of 2 RNs and 1 1. The nursing team consists of 2 RNs and 1 LPN. The assignments would be considered LPN. The assignments would be considered
appropriate if the LPN were assigned to appropriate if the LPN were assigned to which of the following patients?which of the following patients?
A.A. A 3 year old who had an open reduction A 3 year old who had an open reduction of a fractured radius performed of a fractured radius performed yesterday.yesterday.
B.B. A 5 year old who had a tonsillectomy A 5 year old who had a tonsillectomy yesterday.yesterday.
C.C. A 7 year old who is being monitored for a A 7 year old who is being monitored for a seizure disorder.seizure disorder.
D.D. A 2 year old who is receiving a tube A 2 year old who is receiving a tube feeding via a gastrostomy tube. feeding via a gastrostomy tube.
1. The nursing team consists of 2 RNs and 1 1. The nursing team consists of 2 RNs and 1 LPN. The assignments would be considered LPN. The assignments would be considered
appropriate if the LPN were assigned to appropriate if the LPN were assigned to which of the following patients?which of the following patients?
A.A. A 3 year old who had an open reduction of a A 3 year old who had an open reduction of a fractured radius performed yesterday. fractured radius performed yesterday.
B.B. A 5 year old who had a tonsillectomy yesterday.A 5 year old who had a tonsillectomy yesterday.C.C. A 7 year old who is being monitored for a A 7 year old who is being monitored for a
seizure disorder.seizure disorder.
D.D. A 2 year old who is receiving a A 2 year old who is receiving a tube feeding via a gastrostomy tube feeding via a gastrostomy tube. …tube. …Routine task…within her Routine task…within her scope of practice.scope of practice.
Tasks that can be delegated to an Tasks that can be delegated to an LPN/LVNLPN/LVN
Any “regular” procedure that does not Any “regular” procedure that does not require assessment , teaching, or nursing require assessment , teaching, or nursing judgment.judgment.
The technical “doer”The technical “doer” Physical care of clients with more complex Physical care of clients with more complex
conditions, selected treatments.conditions, selected treatments. Must be supervised by an RN.Must be supervised by an RN. Saunders (2008) p.76…dressing changes, Saunders (2008) p.76…dressing changes,
suctioning, urinary catheterization, suctioning, urinary catheterization, medication administration (oral, sq, IM…)medication administration (oral, sq, IM…)
2. A client is admitted to room 703 2. A client is admitted to room 703 with a diagnosis of acute GI bleed. with a diagnosis of acute GI bleed.
Which of the following actions is Which of the following actions is BEST for the RN to take?BEST for the RN to take?
A.A. Ask the UAP to obtain v/s while the RN Ask the UAP to obtain v/s while the RN obtains orders from the MD.obtains orders from the MD.
B.B. Ask the LPN to start an IV while the RN Ask the LPN to start an IV while the RN assesses breath sounds.assesses breath sounds.
C.C. Ask the UAP to obtain equipment needed Ask the UAP to obtain equipment needed for the patient’s care while the RN for the patient’s care while the RN assesses the patient.assesses the patient.
D.D. Ask the LPN to assess the patient while Ask the LPN to assess the patient while the RN reviews orders with the MD. the RN reviews orders with the MD.
22. A client is admitted to room . A client is admitted to room 703703 with a with a diagnosis of acute GI bleed. Which of the diagnosis of acute GI bleed. Which of the
following actions is BEST for the RN to take?following actions is BEST for the RN to take?
A.A. Ask the UAP to obtain v/s while the RN obtains orders Ask the UAP to obtain v/s while the RN obtains orders from the MD. from the MD. Initial v/sInitial v/s
B.B. Ask the LPN to start an IV while the RN assesses Ask the LPN to start an IV while the RN assesses breath sounds. breath sounds. LPN can do aseptic LPN can do aseptic technique…but IV is very invasive and technique…but IV is very invasive and this task would be hospital specific if OK.this task would be hospital specific if OK.
C.C. Ask the UAP to obtain equipment Ask the UAP to obtain equipment needed for the patient’s care while needed for the patient’s care while the RN assesses the patient. the RN assesses the patient.
D.D. Ask the LPN to assess the patient while the RN Ask the LPN to assess the patient while the RN reviews orders with the MD. reviews orders with the MD. AssessmentAssessment
What can be delegated to a What can be delegated to a nursing assistant or a UAP?nursing assistant or a UAP?
Routine, unchanging proceduresRoutine, unchanging procedures Assist with direct patient care Assist with direct patient care
activities under the supervision of an activities under the supervision of an RNRN
Scope of nursing practice is limited.Scope of nursing practice is limited.
How do we prioritize tasks?How do we prioritize tasks?
Maslow’s Hierarchy of NeedsMaslow’s Hierarchy of Needs Basic needs must be met firstBasic needs must be met first Pain is considered a psychosocial Pain is considered a psychosocial
needneed Deal with most acute Deal with most acute actualactual need need
first…first…
3. The RN who is caring for clients in 3. The RN who is caring for clients in the oncology clinic, receives four the oncology clinic, receives four
phone messages. Which call should phone messages. Which call should she return first?she return first?
A.A. A client who is 5 days postop A client who is 5 days postop prostatectomy who complains of chills prostatectomy who complains of chills and a burning sensation with urination.and a burning sensation with urination.
B.B. A client who is receiving chemotherapy A client who is receiving chemotherapy who is experiencing fatigue.who is experiencing fatigue.
C.C. A client newly diagnosed with colon A client newly diagnosed with colon cancer whose stool specimen tested cancer whose stool specimen tested positive for blood.positive for blood.
D.D. A client receiving chemotherapy for lung A client receiving chemotherapy for lung cancer who is experiencing a loss of cancer who is experiencing a loss of appetite. appetite.
3. The RN who is caring for clients in 3. The RN who is caring for clients in the oncology clinic, receives four the oncology clinic, receives four
phone messages. Which call should phone messages. Which call should she return first?she return first?
A.A. A client who is 5 days postop A client who is 5 days postop prostatectomy who complains of prostatectomy who complains of chills and a burning sensation with chills and a burning sensation with urination. …urination. …Most acute…Most acute…
B.B. A client who is receiving chemotherapy who is A client who is receiving chemotherapy who is experiencing fatigue.experiencing fatigue.
C.C. A client newly diagnosed with colon cancer A client newly diagnosed with colon cancer whose stool specimen tested positive for blood.whose stool specimen tested positive for blood.
D.D. A client receiving chemotherapy for lung cancer A client receiving chemotherapy for lung cancer who is experiencing a loss of appetite. who is experiencing a loss of appetite.
4. A nurse from the oncology unit has 4. A nurse from the oncology unit has been pulled to the pediatric unit. been pulled to the pediatric unit.
Which of the following patient Which of the following patient assignments would be BEST for this assignments would be BEST for this
RN?RN?A.A. A newborn newly admitted with A newborn newly admitted with
fever of unknown origin.fever of unknown origin.B.B. A 10-year old who 4 days post A 10-year old who 4 days post
operative appendectomy.operative appendectomy.C.C. A 5-year old newly diagnosed with A 5-year old newly diagnosed with
diabetes.diabetes.D.D. A 12-year old newly diagnosed with A 12-year old newly diagnosed with
a seizure disorder. a seizure disorder.
4. A nurse from the oncology unit has 4. A nurse from the oncology unit has been pulled to the pediatric unit. been pulled to the pediatric unit.
Which of the following patient Which of the following patient assignments would be BEST for this assignments would be BEST for this
RN?RN?A.A. A newborn newly admitted with fever of A newborn newly admitted with fever of
unknown origin. …unknown origin. …Ped. specialty…Ped. specialty…
B.B. A 10-year old who 4 days A 10-year old who 4 days post operative post operative appendectomy.appendectomy.
C.C. A 5-year old newly diagnosed with A 5-year old newly diagnosed with diabetes. diabetes. ..teaching…..teaching…
D.D. A 12-year old newly diagnosed with a A 12-year old newly diagnosed with a seizure disorder. seizure disorder. ..teaching…..teaching…
5. The RN cares for patients on a 5. The RN cares for patients on a medical-surgical nursing unit. Which medical-surgical nursing unit. Which
of the following patients should the RN of the following patients should the RN see FIRST?see FIRST?
A.A. A 91-year old patient who is 72 hours A 91-year old patient who is 72 hours postop colon resection who has a postop colon resection who has a temperature of 100 degrees F.temperature of 100 degrees F.
B.B. A 24-year old patient admitted to rule A 24-year old patient admitted to rule out ectopic pregnancy, whose BP is out ectopic pregnancy, whose BP is 90/58, HR 101.90/58, HR 101.
C.C. A 45-year old patient who was admitted A 45-year old patient who was admitted 24 hours ago with a diagnosis of r/o MI 24 hours ago with a diagnosis of r/o MI whose HR is 72, BP is 145/80.whose HR is 72, BP is 145/80.
D.D. A 50-year old male patient admitted with A 50-year old male patient admitted with the diagnosis: “high blood pressure” who the diagnosis: “high blood pressure” who is complaining of back pain. is complaining of back pain.
5. The RN cares for patients on a 5. The RN cares for patients on a medical-surgical nursing unit. Which medical-surgical nursing unit. Which
of the following patients should the RN of the following patients should the RN see FIRST?see FIRST?
A.A. A 91-year old patient who is 72 hours postop colon A 91-year old patient who is 72 hours postop colon resection who has a temperature of 100 degrees F.resection who has a temperature of 100 degrees F.
B.B. A 24-year old patient admitted to A 24-year old patient admitted to rule out ectopic pregnancy, rule out ectopic pregnancy, whose BP is 90/58, HR 101….most whose BP is 90/58, HR 101….most acute…acute…
C.C. A 45-year old patient who was admitted 24 hours A 45-year old patient who was admitted 24 hours ago with a diagnosis of r/o MI whose HR is 72, BP is ago with a diagnosis of r/o MI whose HR is 72, BP is 145/80.145/80.
D.D. A 50-year old male patient admitted with the A 50-year old male patient admitted with the diagnosis: “high blood pressure” who is diagnosis: “high blood pressure” who is complaining of back pain. complaining of back pain.
6. 6. An adult has been pre-medicated for her An adult has been pre-medicated for her surgery. The operating room (OR) nurse, surgery. The operating room (OR) nurse,
when going through the client’s chart, when going through the client’s chart, realizes that the consent form has not been realizes that the consent form has not been signed. Which of the following is the BEST signed. Which of the following is the BEST
action for the nurse to take?action for the nurse to take?A.A. Assume it is emergency surgery Assume it is emergency surgery
and the consent is implied.and the consent is implied.B.B. Get the consent form and have the Get the consent form and have the
client sign it.client sign it.C.C. Tell the MD that the consent form is Tell the MD that the consent form is
not signed.not signed.D.D. Have a family member sign the Have a family member sign the
consent form. consent form.
6. 6. An adult has been pre-medicated for her An adult has been pre-medicated for her surgery. The operating room (OR) nurse, surgery. The operating room (OR) nurse,
when going through the client’s chart, when going through the client’s chart, realizes that the consent form has not been realizes that the consent form has not been signed. Which of the following is the BEST signed. Which of the following is the BEST
action for the nurse to take?action for the nurse to take?A.A. Assume it is emergency surgery and the Assume it is emergency surgery and the
consent is implied.consent is implied.
B.B. Get the consent form and have the client Get the consent form and have the client sign it.sign it.
C.C. Tell the MD that the consent Tell the MD that the consent form is not signed.form is not signed.
D.D. Have a family member sign the consent Have a family member sign the consent form. form.
7. 7. Which of the following tasks Which of the following tasks could could notnot be delegated to a UAP? be delegated to a UAP?
A.A. A patient with a fractured wrist who A patient with a fractured wrist who needs assistance completing her menu needs assistance completing her menu for the next day.for the next day.
B.B. A patient with left-sided weakness who A patient with left-sided weakness who needs assistance to get out of bed to the needs assistance to get out of bed to the bedside commode.bedside commode.
C.C. A preop patient who needs assistance A preop patient who needs assistance learning to use the incentive Spiro meter.learning to use the incentive Spiro meter.
D.D. A patient who is being started on A patient who is being started on Aldomet and needs his blood pressure Aldomet and needs his blood pressure checked every 4 hours. checked every 4 hours.
7. 7. Which of the following tasks Which of the following tasks could could notnot be delegated to a UAP? be delegated to a UAP?
A.A. A patient with a fractured wrist who needs A patient with a fractured wrist who needs assistance completing her menu for the next day.assistance completing her menu for the next day.
B.B. A patient with left-sided weakness who needs A patient with left-sided weakness who needs assistance to get out of bed to the bedside assistance to get out of bed to the bedside commode.commode.
C.C. A preop patient who needs A preop patient who needs assistance learning to use the assistance learning to use the incentive Spiro meter….incentive Spiro meter….teaching…teaching…
D.D. A patient who is being started on Aldomet and A patient who is being started on Aldomet and needs his blood pressure checked every 4 hours. needs his blood pressure checked every 4 hours. …not the baseline BP – this is just …not the baseline BP – this is just routine monitoring…pts are started routine monitoring…pts are started on Aldomet at the MD’s office and on Aldomet at the MD’s office and allowed to go home to monitor BP…allowed to go home to monitor BP…
8. 8. Which of the following clients Which of the following clients should the nurse deal with first?should the nurse deal with first?
A.A. A client who needs her dressing A client who needs her dressing changed.changed.
B.B. A client who needs his endotracheal A client who needs his endotracheal tube suctioned.tube suctioned.
C.C. A client who needs to be medicated A client who needs to be medicated for postoperative pain.for postoperative pain.
D.D. A client who is incontinent and A client who is incontinent and needs to be cleaned. needs to be cleaned.
8. 8. Which of the following clients Which of the following clients should the nurse deal with first?should the nurse deal with first?
A.A. A client who needs her dressing A client who needs her dressing changed.changed.
B.B. A client who needs his A client who needs his endotracheal tube endotracheal tube suctioned….ABC’s…suctioned….ABC’s…
C.C. A client who needs to be medicated for A client who needs to be medicated for postoperative pain.postoperative pain.
D.D. A client who is incontinent and needs to A client who is incontinent and needs to be cleaned. be cleaned.
9. 9. Which of the following clients Which of the following clients should the nurse observe first?should the nurse observe first?
A.A. A client who has just returned from A client who has just returned from the ORthe OR
B.B. A client whose call light is not A client whose call light is not workingworking
C.C. A client with Alzheimer’s diseaseA client with Alzheimer’s disease
D.D. A client who is receiving a heating A client who is receiving a heating pad treatment. pad treatment.
9. 9. Which of the following clients Which of the following clients should the nurse observe first?should the nurse observe first?
A.A. A client who has just A client who has just returned from the returned from the OR…OR…most most acute, requires assessment…acute, requires assessment…
B.B. A client whose call light is not workingA client whose call light is not working
C.C. A client with Alzheimer’s diseaseA client with Alzheimer’s disease
D.D. A client who is receiving a heating A client who is receiving a heating pad treatment. pad treatment.
10. 10. Four clients have signaled with Four clients have signaled with their call bells for the nurse. Who their call bells for the nurse. Who
should be seen first?should be seen first?
A.A. A client who needs to use the toilet.A client who needs to use the toilet.
B.B. A client who does not have his A client who does not have his glasses or hearing aid.glasses or hearing aid.
C.C. A client who has just been given A client who has just been given morphine.morphine.
D.D. A client in a Geri chair with a A client in a Geri chair with a restraint vest on. restraint vest on.
10. 10. Four clients have signaled with Four clients have signaled with their call bells for the nurse. Who their call bells for the nurse. Who
should be seen first?should be seen first?
A.A. A client who needs to use the toilet.A client who needs to use the toilet.
B.B. A client who does not have his glasses A client who does not have his glasses or hearing aid.or hearing aid.
C.C. A client who has just been A client who has just been given morphine… given morphine… most acutemost acute
D.D. A client in a Geri chair with a restraint A client in a Geri chair with a restraint vest on. vest on.
11. 11. A nursing team consists of an RN, A nursing team consists of an RN, two LPNs, and an UAP. Which of the two LPNs, and an UAP. Which of the following patients should be assigned following patients should be assigned
to the RN?to the RN?A.A. A 3 year old recovering from a gunshot A 3 year old recovering from a gunshot
wound to the abdomen that requires a wound to the abdomen that requires a dressing change.dressing change.
B.B. A 1 year old who is receiving tube A 1 year old who is receiving tube feedings via a nasogastric tube.feedings via a nasogastric tube.
C.C. A 6 year old with cystic fibrosis who A 6 year old with cystic fibrosis who requires chest physiotherapy qid.requires chest physiotherapy qid.
D.D. A 5 year who has been newly diagnosed A 5 year who has been newly diagnosed with diabetes.with diabetes.
11. 11. A nursing team consists of an RN, A nursing team consists of an RN, two LPNs, and an UAP. Which of the two LPNs, and an UAP. Which of the following patients should be assigned following patients should be assigned
to the RN?to the RN?A.A. A 3 year old recovering from a gunshot A 3 year old recovering from a gunshot
wound to the abdomen that requires a wound to the abdomen that requires a dressing change.dressing change.
B.B. A 1 year old who is receiving tube A 1 year old who is receiving tube feedings via a nasogastric tube.feedings via a nasogastric tube.
C.C. A 6 year old with cystic fibrosis who A 6 year old with cystic fibrosis who requires chest physiotherapy qid.requires chest physiotherapy qid.
D.D. A 5 year who has been A 5 year who has been newly diagnosed with newly diagnosed with diabetes. …diabetes. …teaching…teaching…
Don’t forget the basic Don’t forget the basic principles of safety…principles of safety…
12. 12. The nurse enters the dayroom The nurse enters the dayroom and finds a fire. Which is the best and finds a fire. Which is the best
initial action?initial action?
A.A. Evacuate any people in the room, beginning Evacuate any people in the room, beginning with the most ambulatory and ending with with the most ambulatory and ending with the least mobile.the least mobile.
B.B. Activate the fire alarm or call the operator, Activate the fire alarm or call the operator, depending on the institution’s system.depending on the institution’s system.
C.C. Get a fire extinguisher and put out the fire.Get a fire extinguisher and put out the fire.
D.D. Close all the windows and doors, and turn Close all the windows and doors, and turn off any oxygen or electrical appliances. off any oxygen or electrical appliances.
12. 12. The nurse enters the dayroom The nurse enters the dayroom and finds a fire. Which is the best and finds a fire. Which is the best
initial action?initial action?
A.A. Evacuate any people in the Evacuate any people in the room, beginning with the most room, beginning with the most ambulatory and ending with the ambulatory and ending with the least mobile….least mobile….Rescue, Activate, Rescue, Activate, Confine, Extinguish …Confine, Extinguish …
B.B. Activate the fire alarm or call the operator, Activate the fire alarm or call the operator, depending on the institution’s system.depending on the institution’s system.
C.C. Get a fire extinguisher and put out the fire.Get a fire extinguisher and put out the fire.D.D. Close all the windows and doors, and turn off Close all the windows and doors, and turn off
any oxygen or electrical appliances. any oxygen or electrical appliances.
1313. The patient reports to you that he . The patient reports to you that he noticed that $20.00 was missing from his noticed that $20.00 was missing from his
bedside table after the Respiratory Therapist bedside table after the Respiratory Therapist finished his treatment. What action should finished his treatment. What action should
you take?you take?A.A. Ask the Respiratory Therapist if he knows Ask the Respiratory Therapist if he knows
anything about the missing money.anything about the missing money.B.B. Report the missing money to the head of Report the missing money to the head of
the Respiratory Therapy department.the Respiratory Therapy department.C.C. Report the missing money to your Report the missing money to your
immediate supervisor.immediate supervisor.D.D. Record the missing money in the nurses’ Record the missing money in the nurses’
notes – the MD will follow up when he notes – the MD will follow up when he reads your note later in the day.reads your note later in the day.
1313. The patient reports to you that he . The patient reports to you that he noticed that $20.00 was missing from his noticed that $20.00 was missing from his
bedside table after the Respiratory Therapist bedside table after the Respiratory Therapist finished his treatment. What action should finished his treatment. What action should
you take?you take?A.A. Ask the Respiratory Therapist if he knows Ask the Respiratory Therapist if he knows
anything about the missing money.anything about the missing money.B.B. Report the missing money to the head of Report the missing money to the head of
the Respiratory Therapy department.the Respiratory Therapy department.
C.C. Report the missing money to Report the missing money to your immediate supervisor… your immediate supervisor… chain of command …chain of command …
D.D. Record the missing money in the nurses’ Record the missing money in the nurses’ notes – the MD will follow up when he notes – the MD will follow up when he reads your note later in the day.reads your note later in the day.
Chain of CommandChain of Command
Always report to the RN in the Always report to the RN in the scenario’s immediate supervisor.scenario’s immediate supervisor.
14. 14. An adult has just arrived on the unit An adult has just arrived on the unit after surgery. Which of the following is the after surgery. Which of the following is the
most appropriate task for the nurse to most appropriate task for the nurse to delegate to the certified nursing assistant delegate to the certified nursing assistant
(CNA)?(CNA)?
A.A. Assessment of the vital signs while the Assessment of the vital signs while the RN watches.RN watches.
B.B. Suctioning the tracheotomy and Suctioning the tracheotomy and reporting back to the nurse.reporting back to the nurse.
C.C. Changing the client’s postoperative Changing the client’s postoperative dressing and then describing it to the RN.dressing and then describing it to the RN.
D.D. Measure the amount of urine in the Measure the amount of urine in the Urinary Drainage Bag. Urinary Drainage Bag.
14. 14. An adult has just arrived on the unit An adult has just arrived on the unit after surgery. Which of the following is the after surgery. Which of the following is the
most appropriate task for the nurse to most appropriate task for the nurse to delegate to the certified nursing assistant delegate to the certified nursing assistant
(CNA)?(CNA)?
A.A. Assessment of the vital signs while the RN Assessment of the vital signs while the RN watches.watches.
B.B. Suctioning the tracheotomy and reporting Suctioning the tracheotomy and reporting back to the nurse.back to the nurse.
C.C. Changing the client’s postoperative Changing the client’s postoperative dressing and then describing it to the RN.dressing and then describing it to the RN.
D.D. Measure the amount of urine Measure the amount of urine in the Urinary Drainage Bag. in the Urinary Drainage Bag.
15. The nurse is making the 15. The nurse is making the assignment for the floor. There is one assignment for the floor. There is one
LPN and three RNs. Which of the LPN and three RNs. Which of the following clients should the LPN be following clients should the LPN be
assigned to care for?assigned to care for?A.A. A client who is intubated and a newly A client who is intubated and a newly
diagnosed diabetic.diagnosed diabetic.
B.B. A recent ICU transfer and a person with A recent ICU transfer and a person with AIDS.AIDS.
C.C. A client awaiting a nursing home bed and A client awaiting a nursing home bed and a client one day post-hernia repair.a client one day post-hernia repair.
D.D. A new admission for cholecystectomy A new admission for cholecystectomy and a client one day post-op and a client one day post-op mastectomy. mastectomy.
15. The nurse is making the 15. The nurse is making the assignment for the floor. There is one assignment for the floor. There is one
LPN and three RNs. Which of the LPN and three RNs. Which of the following clients should the LPN be following clients should the LPN be
assigned to care for?assigned to care for?A.A. A client who is intubated and a newly A client who is intubated and a newly
diagnosed diabetic.diagnosed diabetic.B.B. A recent ICU transfer and a person with A recent ICU transfer and a person with
AIDS.AIDS.
C.C. A client awaiting a nursing A client awaiting a nursing home bed and a client one day home bed and a client one day post-hernia repair. … post-hernia repair. … least least acute…acute…
D.D. A new admission for cholecystectomy and a A new admission for cholecystectomy and a client one day post-op mastectomy. client one day post-op mastectomy.
1616. The nurse is unfamiliar with a new . The nurse is unfamiliar with a new piece of OR equipment that is piece of OR equipment that is
scheduled to be used today. What is scheduled to be used today. What is the best course of action?the best course of action?
A.A. Ask another nurse for instructions on Ask another nurse for instructions on how to use it.how to use it.
B.B. Wait until she has attended a class Wait until she has attended a class on using the equipment before using on using the equipment before using it.it.
C.C. Get another nurse who is familiar Get another nurse who is familiar with the equipment to operate it.with the equipment to operate it.
D.D. Read the instructions provided with Read the instructions provided with the equipment. the equipment.
16.16. The nurse is unfamiliar with a new The nurse is unfamiliar with a new piece of OR equipment that is piece of OR equipment that is scheduled to be used today. What scheduled to be used today. What is the best course of action?is the best course of action?
A.A. Ask another nurse for instructions on how to use Ask another nurse for instructions on how to use it.it.
B.B. Wait until she has attended a class on using the Wait until she has attended a class on using the equipment before using it… equipment before using it… ideally… ideally…
C.C. Get another nurse who is Get another nurse who is familiar with the equipment to familiar with the equipment to operate it.operate it.
D.D. Read the instructions provided with the Read the instructions provided with the equipment. equipment.
•Confused
•Unsure of how to do something
•Unsure of how something works
Never attempt a task you have not Never attempt a task you have not been trained to dobeen trained to do
Always follow manufacturer's Always follow manufacturer's guidelinesguidelines
17. 17. An adult has developed a stage II An adult has developed a stage II pressure ulcer. He is scheduled to receive pressure ulcer. He is scheduled to receive wet to dry dressings every shift. Which of wet to dry dressings every shift. Which of the following team members would be the the following team members would be the
BEST choice to perform this task?BEST choice to perform this task?
A.A. An LPN who has worked on the nursing unit An LPN who has worked on the nursing unit for 6 months.for 6 months.
B.B. A UAP who will graduate from a A UAP who will graduate from a baccalaureate nursing program in 10 days.baccalaureate nursing program in 10 days.
C.C. A nursing assistant with 10 years A nursing assistant with 10 years experience on this nursing unit.experience on this nursing unit.
D.D. An LPN from the Surgical ICU who has been An LPN from the Surgical ICU who has been pulled to the nursing unit to help out today. pulled to the nursing unit to help out today.
17. 17. An adult has developed a stage II An adult has developed a stage II pressure ulcer. He is scheduled to receive pressure ulcer. He is scheduled to receive wet to dry dressings every shift. Which of wet to dry dressings every shift. Which of the following team members would be the the following team members would be the
BEST choice to perform this task?BEST choice to perform this task?
A.A. An LPN who has worked on the An LPN who has worked on the nursing unit for 6 months.nursing unit for 6 months.
B.B. A UAP who will graduate from a A UAP who will graduate from a baccalaureate nursing program in 10 days.baccalaureate nursing program in 10 days.
C.C. A nursing assistant with 10 years experience A nursing assistant with 10 years experience on this nursing unit.on this nursing unit.
D.D. An LPN who has been pulled to the nursing An LPN who has been pulled to the nursing unit to help out today. unit to help out today.
18.18. The nurse is about to administer the premedication The nurse is about to administer the premedication prescribed for a woman scheduled for a prescribed for a woman scheduled for a lumpectomy. The client says, “I’ll be glad when the lumpectomy. The client says, “I’ll be glad when the surgery is over. It will eliminate all the cancer from surgery is over. It will eliminate all the cancer from my body.” Which of the following is the BEST action my body.” Which of the following is the BEST action for the nurse to take?for the nurse to take?
A.A. Medicate the client and tell the MD.Medicate the client and tell the MD.
B.B. Correct the client’s misconceptions.Correct the client’s misconceptions.
C.C. Call the MD without medicating the client.Call the MD without medicating the client.
D.D. Give the medications to the client and note her Give the medications to the client and note her comment in the chart comment in the chart
18.18. The nurse is about to administer the premedication The nurse is about to administer the premedication prescribed for a woman scheduled for a prescribed for a woman scheduled for a lumpectomy. The client says, “I’ll be glad when the lumpectomy. The client says, “I’ll be glad when the surgery is over. It will eliminate all the cancer from surgery is over. It will eliminate all the cancer from my body.” Which of the following is the BEST action my body.” Which of the following is the BEST action for the nurse to take?for the nurse to take?
A.A. Medicate the client and tell the MD.Medicate the client and tell the MD.
B.B. Correct the client’s misconceptions.Correct the client’s misconceptions.
C.C. Call the MD without Call the MD without medicating the client.medicating the client.
D.D. Give the medications to the client Give the medications to the client and note her comment in the chart and note her comment in the chart
19.19. The nursing team, consisting of one The nursing team, consisting of one RN, one LPN, and one nursing assistant RN, one LPN, and one nursing assistant has just received report from the has just received report from the previous shift. At the completion of the previous shift. At the completion of the report, what action should the RN take report, what action should the RN take FIRST?FIRST?
A.A. Make assignments for the members of Make assignments for the members of the nursing team.the nursing team.
B.B. Assess each patient that will be cared for Assess each patient that will be cared for by the nursing team.by the nursing team.
C.C. Assess a patient who complains that the Assess a patient who complains that the PCA has suddenly stopped controlling his PCA has suddenly stopped controlling his postop pain.postop pain.
D.D. Assess a patient who is requesting his Assess a patient who is requesting his prescribed prn for pain.prescribed prn for pain.
19.19. The nursing team, consisting of one The nursing team, consisting of one RN, one LPN, and one nursing assistant RN, one LPN, and one nursing assistant has just received report from the has just received report from the previous shift. At the completion of the previous shift. At the completion of the report, what action should the RN take report, what action should the RN take FIRST?FIRST?
A.A. Make assignments for the members of the Make assignments for the members of the nursing team.nursing team.
B.B. Assess each patient that will be cared for by the Assess each patient that will be cared for by the nursing team.nursing team.
C.C. Assess a patient who complains Assess a patient who complains that the PCA has suddenly that the PCA has suddenly stopped controlling his postop stopped controlling his postop pain.pain.
D.D. Assess a patient who is requesting his Assess a patient who is requesting his prescribed prn for pain.prescribed prn for pain.
20. An RN who works in labor and delivery has 20. An RN who works in labor and delivery has been pulled to a medical nursing unit that been pulled to a medical nursing unit that
specializes in diabetes to assist with patient specializes in diabetes to assist with patient care during the 7-3 shift. Which of the care during the 7-3 shift. Which of the following patient assignments would be following patient assignments would be
appropriate for this RN?appropriate for this RN?
A.A. A patient who is on an insulin drip.A patient who is on an insulin drip.B.B. A patient with a new diagnosis of A patient with a new diagnosis of
diabetes.diabetes.C.C. A patient who has received an A patient who has received an
insulin pump and is being prepared insulin pump and is being prepared for discharge.for discharge.
D.D. A patient who is being treated for A patient who is being treated for high blood pressure. high blood pressure.
20. An RN who works in labor and delivery has 20. An RN who works in labor and delivery has been pulled to a medical nursing unit that been pulled to a medical nursing unit that
specializes in diabetes to assist with patient specializes in diabetes to assist with patient care during the 7-3 shift. Which of the care during the 7-3 shift. Which of the following patient assignments would be following patient assignments would be
appropriate for this RN?appropriate for this RN?
A.A. A patient who is on an insulin drip.A patient who is on an insulin drip.
B.B. A patient with a new diagnosis of diabetes.A patient with a new diagnosis of diabetes.
C.C. A patient who has received an insulin pump A patient who has received an insulin pump and is being prepared for discharge.and is being prepared for discharge.
D.D. A patient who is being A patient who is being treated for high blood treated for high blood pressure. pressure.
21. The nurse evaluates assignments 21. The nurse evaluates assignments on a medical/surgical unit. The on a medical/surgical unit. The
assignments are deemed appropriate assignments are deemed appropriate if a nursing assistant performs which if a nursing assistant performs which
of the following tasks?of the following tasks?A.A. Admission vital signs for a patient who Admission vital signs for a patient who
is scheduled for surgery tomorrow.is scheduled for surgery tomorrow.B.B. Before lunch accucheck for a patient Before lunch accucheck for a patient
who is receiving hyperalimentation who is receiving hyperalimentation fluids.fluids.
C.C. A dressing change for a client with a A dressing change for a client with a pressure ulcer.pressure ulcer.
D.D. Discharge teaching for a client Discharge teaching for a client diagnosed with COPD. diagnosed with COPD.
21. The nurse evaluates assignments 21. The nurse evaluates assignments on a medical/surgical unit. The on a medical/surgical unit. The
assignments are assignments are deemed deemed appropriateappropriate if a nursing assistant if a nursing assistant
performs which of the following tasks?performs which of the following tasks?A.A. Admission vital signs for a patient who is Admission vital signs for a patient who is
scheduled for surgery tomorrow.scheduled for surgery tomorrow.
B. Before lunch accucheck for a patient who is receiving hyperalimentation fluids…not a new HAF administration…
C.C. A dressing change for a client with a A dressing change for a client with a pressure ulcer.pressure ulcer.
D.D. Discharge teaching for a client diagnosed Discharge teaching for a client diagnosed with COPD. with COPD.
22. 22. The nursing team consists of one The nursing team consists of one RN, one LPN, and one nursing RN, one LPN, and one nursing
assistant. Which of the following assistant. Which of the following patients should the RN attend to patients should the RN attend to
FIRST?FIRST?A.A. A patient who is experiencing dysuria A patient who is experiencing dysuria
after a cystoscope.after a cystoscope.B.B. A patient whose BP has changed from A patient whose BP has changed from
160/82 to 92/75.160/82 to 92/75.C.C. A patient who is experiencing incisional A patient who is experiencing incisional
pain 24 hours postop cholecystectomy.pain 24 hours postop cholecystectomy.D.D. A patient who is visually impaired who A patient who is visually impaired who
needs assistance to get OOB to the needs assistance to get OOB to the bedside commode. bedside commode.
22. 22. The nursing team consists of one The nursing team consists of one RN, one LPN, and one nursing RN, one LPN, and one nursing
assistant. Which of the following assistant. Which of the following patients should the RN attend to patients should the RN attend to
FIRST?FIRST?A.A. A patient who is experiencing dysuria after A patient who is experiencing dysuria after
a cystoscope.a cystoscope.
B.B. A patient whose BP has A patient whose BP has changed from 160/82 to 92/75.changed from 160/82 to 92/75.
C.C. A patient who is experiencing incisional pain A patient who is experiencing incisional pain 24 hours postop cholecystectomy.24 hours postop cholecystectomy.
D.D. A patient who is visually impaired who A patient who is visually impaired who needs assistance to get OOB to the bedside needs assistance to get OOB to the bedside commode. commode.
23. 23. Mr. Smith in RM 412 has a living Mr. Smith in RM 412 has a living will. The RN should consult this will. The RN should consult this
document prior to the implementation document prior to the implementation of which of the following MD orders?of which of the following MD orders?
A.A. Turn, cough, deep breath q 2hours Turn, cough, deep breath q 2hours while awake.while awake.
B.B. Osmolite 500ml QID via PEG tube.Osmolite 500ml QID via PEG tube.
C.C. OOB QID to bedside chair.OOB QID to bedside chair.
D.D. Active ROM exercises QID. Active ROM exercises QID.
23. 23. Mr. Smith in RM 412 has a living Mr. Smith in RM 412 has a living will. The RN should consult this will. The RN should consult this
document prior to the implementation document prior to the implementation of which of the following MD orders?of which of the following MD orders?
A.A. Turn, cough, deep breath q 2hours Turn, cough, deep breath q 2hours while awake.while awake.
B.B. Osmolite 500ml QID via Osmolite 500ml QID via PEG tube. …PEG tube. …life sustaininglife sustaining txtx……
C.C. OOB QID to bedside chair.OOB QID to bedside chair.
D.D. Active ROM exercises QID. Active ROM exercises QID.
24. Which phone call should 24. Which phone call should the RN return first?the RN return first?
A.A. A patient who is 5 days postop A patient who is 5 days postop hysterectomy who is complaining of hysterectomy who is complaining of severe abdominal pain.severe abdominal pain.
B.B. A patient receiving chemotherapy who is A patient receiving chemotherapy who is complaining of discomfort secondary to complaining of discomfort secondary to oral lesions.oral lesions.
C.C. A patient 2 days postop Laparoscopic A patient 2 days postop Laparoscopic Cholecystectomy who is complaining of Cholecystectomy who is complaining of abdominal distention. abdominal distention.
D.D. A dialysis patient who complains of dry, A dialysis patient who complains of dry, itchy skin. itchy skin.
24. Which phone call should 24. Which phone call should the RN return first?the RN return first?
A.A. A patient who is 5 days postop A patient who is 5 days postop hysterectomy who is complaining hysterectomy who is complaining of severe abdominal pain.of severe abdominal pain.
B.B. A patient receiving chemotherapy who is A patient receiving chemotherapy who is complaining of discomfort secondary to oral lesions.complaining of discomfort secondary to oral lesions.
C.C. A patient 2 days postop Laparoscopic A patient 2 days postop Laparoscopic Cholecystectomy who is complaining of abdominal Cholecystectomy who is complaining of abdominal distention. distention.
D.D. A dialysis patient who complains of dry, itchy skin. A dialysis patient who complains of dry, itchy skin.
25.25. The nurse instructs the nursing assistant to The nurse instructs the nursing assistant to assist her in obtaining output measurements assist her in obtaining output measurements for a patient receiving Lasix. There would be for a patient receiving Lasix. There would be cause for concern if the instructions given to cause for concern if the instructions given to the nursing student included which of the the nursing student included which of the following:following:
A.A. Empty the urinary drainage bag into the Empty the urinary drainage bag into the measuring device kept in the patient’s measuring device kept in the patient’s bathroom.bathroom.
B.B. Palpate the patient’s abdomen to Palpate the patient’s abdomen to determine if his bladder is empty.determine if his bladder is empty.
C.C. Milk the urine in the drainage tubing into Milk the urine in the drainage tubing into the urinary drainage bag prior to the urinary drainage bag prior to emptying the bag. emptying the bag.
D.D. Report back to me with a description of Report back to me with a description of the color and amount of urine the color and amount of urine
25.25. The nurse instructs the nursing assistant to The nurse instructs the nursing assistant to assist her in obtaining output assist her in obtaining output measurements for a patient receiving Lasix. measurements for a patient receiving Lasix. There would be cause for concern if the There would be cause for concern if the instructions given to the nursing student instructions given to the nursing student included which of the following:included which of the following:
A.A. Empty the urinary drainage bag into the Empty the urinary drainage bag into the measuring device kept in the patient’s measuring device kept in the patient’s bathroom.bathroom.
B.B. Palpate the patient’s abdomen Palpate the patient’s abdomen to determine if his bladder is to determine if his bladder is empty.empty.
C.C. Milk the urine in the drainage tubing into the Milk the urine in the drainage tubing into the urinary drainage bag prior to emptying the bag. urinary drainage bag prior to emptying the bag.
D.D. Report back to me with a description of the Report back to me with a description of the color and amount of urine color and amount of urine
2626. A male UAP complains to the RN . A male UAP complains to the RN that another RN on the unit often slaps that another RN on the unit often slaps
him on the buttocks. What action him on the buttocks. What action should the RN take?should the RN take?
A.A. Report the complaint to her immediate Report the complaint to her immediate supervisor.supervisor.
B.B. Discuss the complaint with the other RN.Discuss the complaint with the other RN.
C.C. Ensure that in the future that Ensure that in the future that assignments are made in such a way assignments are made in such a way that these two individuals will not be that these two individuals will not be working with each other.working with each other.
D.D. Complete an incident report about this Complete an incident report about this complaint. complaint.
26.26. A male UAP complains to the RN A male UAP complains to the RN that another RN on the unit often that another RN on the unit often slaps him on the buttocks. What slaps him on the buttocks. What action should the RN take?action should the RN take?
A.A. Report the complaint to her Report the complaint to her immediate supervisor.immediate supervisor.
B.B. Discuss the complaint with the other RN.Discuss the complaint with the other RN.
C.C. Ensure that in the future that assignments Ensure that in the future that assignments are made in such a way that these two are made in such a way that these two individuals will not be working with each individuals will not be working with each other.other.
D.D. Complete an incident report about this Complete an incident report about this complaint. complaint.
27.27. An RN from the ICU is pulled to the An RN from the ICU is pulled to the oncology unit. Which assignment oncology unit. Which assignment is most appropriate for this RN to is most appropriate for this RN to
take?take? A.A. A 45-year old after a colon resection.A 45-year old after a colon resection.
B.B. A 92-year old comatose patient in A 92-year old comatose patient in the terminal stages of gastric the terminal stages of gastric cancer.cancer.
C.C. A 21-year old receiving 5FU IV.A 21-year old receiving 5FU IV.
D.D. A 65-year old with a positive A 65-year old with a positive prostate biopsy. prostate biopsy.
27.27. An RN from the ICU is pulled to the An RN from the ICU is pulled to the oncology unit. Which assignment oncology unit. Which assignment is most appropriate for this RN to is most appropriate for this RN to
take?take? A.A. A 45-year old after a colon A 45-year old after a colon
resection.resection.B.B. A 92-year old comatose patient in the A 92-year old comatose patient in the
terminal stages of gastric cancer.terminal stages of gastric cancer.
C.C. A 21-year old receiving 5FU IV.A 21-year old receiving 5FU IV.
D.D. A 65-year old with a positive prostate A 65-year old with a positive prostate biopsy. biopsy.
28.28. A bomb has just exploded at a A bomb has just exploded at a local school. What would be the local school. What would be the MOST appropriate action for an RN MOST appropriate action for an RN with 20 years experience on a with 20 years experience on a medical-surgical nursing unit to medical-surgical nursing unit to take?take?
A.A. Drive immediately to the site of the Drive immediately to the site of the disaster and begin working with victims disaster and begin working with victims inside the building.inside the building.
B.B. Contact all the RNs she knows who live Contact all the RNs she knows who live within 5 miles of the school to encourage within 5 miles of the school to encourage them to go to the site and begin assisting them to go to the site and begin assisting victims.victims.
C.C. Contact the closest hospital to the Contact the closest hospital to the disaster and volunteer her services.disaster and volunteer her services.
D.D. Drive immediately to the school to assist Drive immediately to the school to assist distraught parents. distraught parents.
28.28. A bomb has just exploded at a A bomb has just exploded at a local school. What would be the local school. What would be the MOST appropriate action for an RN MOST appropriate action for an RN with 20 years experience on a with 20 years experience on a medical-surgical nursing unit to medical-surgical nursing unit to take?take?
A.A. Drive immediately to the site of the disaster and Drive immediately to the site of the disaster and begin working with victims inside the building.begin working with victims inside the building.
B.B. Contact all the RNs she knows who live within 5 Contact all the RNs she knows who live within 5 miles of the school to encourage them to go to miles of the school to encourage them to go to the site and begin assisting victims.the site and begin assisting victims.
C.C. Contact the closest hospital to Contact the closest hospital to the disaster and volunteer her the disaster and volunteer her services.services.
D.D. Drive immediately to the school to assist Drive immediately to the school to assist distraught parents. distraught parents.
What is meant by the term What is meant by the term Triage?Triage?
29. 29. The following represents the The following represents the categories that can be used to assist categories that can be used to assist with triage of disaster victims. Which with triage of disaster victims. Which
category would be seen first?category would be seen first?
A.A. YellowYellow
B.B. GreenGreen
C.C. RedRed
D.D. Black Black
29.29. The following represents the The following represents the categories that can be used to categories that can be used to assist with triage of disaster assist with triage of disaster victims. Which category would be victims. Which category would be seen first?seen first?
A.A. YellowYellow
B.B. GreenGreen
C.C.RedRedD.D. Black Black
Red: Immediate Care. Class I. Critical, life Red: Immediate Care. Class I. Critical, life threatening. Compromised airway, shock, threatening. Compromised airway, shock, hemorrhagehemorrhage
Yellow: Minimal Care. Urgent. Class II. Yellow: Minimal Care. Urgent. Class II. Major illness or injury. Requires treatment Major illness or injury. Requires treatment within 20 minutes to 2 hours. Open within 20 minutes to 2 hours. Open fracture. Chest wound.fracture. Chest wound.
Green: Delayed Care. Class III. Care may be Green: Delayed Care. Class III. Care may be delayed 2 hours or more. Minor injuries; delayed 2 hours or more. Minor injuries; walking wounded, closed fracture, sprain, walking wounded, closed fracture, sprain, strain.strain.
Black: Expectant Care. Class IV. Dead or Black: Expectant Care. Class IV. Dead or expected to die. Massive head injury. expected to die. Massive head injury. Extensive full-thickness burns.Extensive full-thickness burns.
30. 30. The RN at the Home Nursing The RN at the Home Nursing agency receives messages from four of agency receives messages from four of her patients. Which patient should she her patients. Which patient should she
contact FIRST?contact FIRST?A.A. 45 year old patient with Bronchitis who 45 year old patient with Bronchitis who
has been experiencing vomiting and has been experiencing vomiting and diarrhea for 24 hours.diarrhea for 24 hours.
B.B. 51 year old patient with Diabetes whose 51 year old patient with Diabetes whose AM blood sugar was 175.AM blood sugar was 175.
C.C. 49 year old patient with peripheral 49 year old patient with peripheral vascular disease who complains of “cold vascular disease who complains of “cold feet”.feet”.
D.D. 55 year old patient with essential 55 year old patient with essential hypertension who experiences “light-hypertension who experiences “light-headedness” when he stands up. headedness” when he stands up.
30. 30. The RN at the Home Nursing agency The RN at the Home Nursing agency receives messages from four of her receives messages from four of her
patients. Which patient should she contact patients. Which patient should she contact FIRST?FIRST?
A.A. 45 year old patient with 45 year old patient with Bronchitis who has been Bronchitis who has been experiencing vomiting and experiencing vomiting and diarrhea for 24 hours.diarrhea for 24 hours.
B.B. 51 year old patient with Diabetes whose AM 51 year old patient with Diabetes whose AM blood sugar was 175.blood sugar was 175.
C.C. 49 year old patient with peripheral vascular 49 year old patient with peripheral vascular disease who complains of “cold feet”.disease who complains of “cold feet”.
D.D. 55 year old patient with essential hypertension 55 year old patient with essential hypertension who experiences “light-headedness” when he who experiences “light-headedness” when he stands up. stands up.
31.31. The RN in an Emergency Department has been The RN in an Emergency Department has been asked to use the California Fire Chiefs Association asked to use the California Fire Chiefs Association Victim triage tag system. Which of the following Victim triage tag system. Which of the following individuals would be classified in the “Green” individuals would be classified in the “Green” category (care may be delayed 2 hours or more):category (care may be delayed 2 hours or more):
A.A. A patient who is conscious and has A patient who is conscious and has sustained an opened fracture of the femur.sustained an opened fracture of the femur.
B.B. A patient who is conscious and does not A patient who is conscious and does not appear to have any injuries of any type.appear to have any injuries of any type.
C.C. A patient who is conscious and has A patient who is conscious and has sustained multiple scrapes and bruising of sustained multiple scrapes and bruising of the face and upper body.the face and upper body.
D.D. A patient who is unconscious and has an A patient who is unconscious and has an open skull fracture. open skull fracture.
31.31. The RN in an Emergency Department has The RN in an Emergency Department has been asked to use the California Fire Chiefs been asked to use the California Fire Chiefs Association Victim triage tag system. Which Association Victim triage tag system. Which of the following individuals would be of the following individuals would be classified in the “Green” category classified in the “Green” category (care may be (care may be
delayed 2 hours or more):delayed 2 hours or more): : :A.A. A patient who is conscious and has sustained an opened A patient who is conscious and has sustained an opened
fracture of the femur. …fracture of the femur. …Yellow (treatment within Yellow (treatment within 2 hrs to 20 minutes)2 hrs to 20 minutes)
B.B. A patient who is conscious and does not appear to have A patient who is conscious and does not appear to have any injuries of any type.any injuries of any type.
C.C. A patient who is conscious and has A patient who is conscious and has sustained multiple scrapes and bruising of sustained multiple scrapes and bruising of the face and upper body.the face and upper body.
D.D. A patient who is unconscious and has an open skull A patient who is unconscious and has an open skull fracture. fracture. …red (immediate care to save life/ …red (immediate care to save life/ critical care) black (if severe head injury …critical care) black (if severe head injury …expectant care only)expectant care only)
32. The patient the RN is assessing at 32. The patient the RN is assessing at the scene of a disaster has full the scene of a disaster has full
thickness burns that cover 90 percent thickness burns that cover 90 percent of his body. What classification would of his body. What classification would
he be given?he be given?A.A. RedRed
B.B. YellowYellow
C.C. GreenGreen
D.D. BlackBlack
32. The patient the RN is assessing at 32. The patient the RN is assessing at the scene of a disaster has full the scene of a disaster has full
thickness burns that cover 90 percent thickness burns that cover 90 percent of his body. What classification would of his body. What classification would
he be given?he be given?A.A. Red (critical care intervention Red (critical care intervention
immediately)immediately)
B.B. Yellow (20 minutes to 2 hours)Yellow (20 minutes to 2 hours)
C.C. Green (needs to be seen but care can Green (needs to be seen but care can be delayed for 2 hours or more without be delayed for 2 hours or more without significantly impacting pt outcomes)significantly impacting pt outcomes)
D.D.BlackBlack (death anticipated… (death anticipated…expectant care)expectant care)
3333. After receiving report from the 11-. After receiving report from the 11-7 shift nurse, which of the following 7 shift nurse, which of the following
should the nurse see first?should the nurse see first?A.A. A 40-year old client who had gastric A 40-year old client who had gastric
bypass surgery yesterday.bypass surgery yesterday.B.B. A 21 year-old who has suddenly A 21 year-old who has suddenly
developed wheezes.developed wheezes.C.C. A 75 year old client with left-sided A 75 year old client with left-sided
weakness who is requesting assistance weakness who is requesting assistance to the bedside commode.to the bedside commode.
D.D. A 32-year old who is refusing her A 32-year old who is refusing her morning dose of Lasix. morning dose of Lasix.
3333. After receiving report from the 11-. After receiving report from the 11-7 shift nurse, which of the following 7 shift nurse, which of the following
should the nurse see first?should the nurse see first?A.A. A 40-year old client who had gastric bypass A 40-year old client who had gastric bypass
surgery yesterday.surgery yesterday.
B.B. A 21 year-old who has A 21 year-old who has suddenly developed wheezes.suddenly developed wheezes.
C.C. A 75 year old client with left-sided A 75 year old client with left-sided weakness who is requesting assistance to weakness who is requesting assistance to the bedside commode.the bedside commode.
D.D. A 32-year old who is refusing her morning A 32-year old who is refusing her morning dose of Lasix. dose of Lasix.
Chemical Incidents
34.34. Triage in the field for chemical incidents are divided into the Triage in the field for chemical incidents are divided into the “Hot Zone”, “Warm Zone”, and the “Cold Zone”. An individual “Hot Zone”, “Warm Zone”, and the “Cold Zone”. An individual who is considered contaminated, but is a Code Red (requires who is considered contaminated, but is a Code Red (requires immediate intervention to survive) would be taken to which immediate intervention to survive) would be taken to which area first?area first?
A.A. A code red patient is taken immediately to the A code red patient is taken immediately to the hospital. The EMT’s perform chemical hospital. The EMT’s perform chemical decontamination on this individual en route to the decontamination on this individual en route to the hospital.hospital.
B.B. All patients are taken to the “Hot Zone” first for All patients are taken to the “Hot Zone” first for minimal triage and medical care. Triage is done in minimal triage and medical care. Triage is done in this area to determine expectant status.this area to determine expectant status.
C.C. This patient would proceed directly to the Cold Zone This patient would proceed directly to the Cold Zone for treatment and would skip the decontamination for treatment and would skip the decontamination process.process.
D.D. A code red patient would not be removed from the A code red patient would not be removed from the contaminated area as his chances of survival are contaminated area as his chances of survival are poor.poor.
34.34. Triage in the field for chemical incidents are Triage in the field for chemical incidents are divided into the “Hot Zone”, “Warm Zone”, divided into the “Hot Zone”, “Warm Zone”, and the “Cold Zone”. An individual who is and the “Cold Zone”. An individual who is considered contaminated, but is a Code Red considered contaminated, but is a Code Red would be taken to which area first?would be taken to which area first?
A.A. A code red patient is taken immediately to the hospital. A code red patient is taken immediately to the hospital. The EMT’s perform chemical decontamination on this The EMT’s perform chemical decontamination on this individual en route to the hospital.individual en route to the hospital.
B.B. All patients are taken to the “Hot All patients are taken to the “Hot Zone” first for minimal triage and Zone” first for minimal triage and medical care. Triage is done in this medical care. Triage is done in this area to determine expectant status.area to determine expectant status.
C.C. This patient would proceed directly to the Cold Zone for This patient would proceed directly to the Cold Zone for treatment and would skip the decontamination process.treatment and would skip the decontamination process.
D.D. A code red patient would not be removed from the A code red patient would not be removed from the contaminated area as his chances of survival are poor.contaminated area as his chances of survival are poor.
In the Field:In the Field:
Hot Zone: area Hot Zone: area immediately adjacent to immediately adjacent to the location of the the location of the incident. Minimal incident. Minimal triage/medical care – triage/medical care – limited to airway and limited to airway and hemorrhage control, hemorrhage control, administration of administration of antidotes, and antidotes, and identification of expectant identification of expectant cases.cases.
In the Field….In the Field….
Warm Zone: a distance of at least 300 Warm Zone: a distance of at least 300 feet from the outer perimeter of the feet from the outer perimeter of the hot zone. hot zone. Upwind, uphillUpwind, uphill from from the contaminated area. Rapid triage the contaminated area. Rapid triage to determine expectant status. to determine expectant status. Minimal treatment. Priority is to Minimal treatment. Priority is to decontaminate.decontaminate.
In the Field….In the Field….
Cold Zone: Area adjacent (Cold Zone: Area adjacent (uphill uphill and upwindand upwind) from warm zone. ) from warm zone. Decontaminated victims seen. Decontaminated victims seen. Thorough triage. Victims directed for Thorough triage. Victims directed for treatment.treatment.
35. Staff in the field must wear 35. Staff in the field must wear protective gear in which of protective gear in which of
the following areas:the following areas:A.A. Hot Zone only.Hot Zone only.
B.B. Warm Zone only.Warm Zone only.
C.C. Hot and warm zones, required in Hot and warm zones, required in cold zone if unable to secure a cold zone if unable to secure a location for this zone which is uphill location for this zone which is uphill and upwind.and upwind.
D.D. Hot, Warm, and Cold Zone.Hot, Warm, and Cold Zone.
35. Staff in the field must wear 35. Staff in the field must wear protective gear in which of protective gear in which of
the following areas:the following areas:A.A. Hot Zone only.Hot Zone only.
B.B. Warm Zone only.Warm Zone only.
C.C. Hot and warm zones, required in cold Hot and warm zones, required in cold zone if unable to secure a location for zone if unable to secure a location for this zone which is uphill and upwind.this zone which is uphill and upwind.
D.D.Hot, Warm, and Cold Zone.Hot, Warm, and Cold Zone.
36. Which of the following patients 36. Which of the following patients could enter the area designated as the could enter the area designated as the
“cold zone”?“cold zone”?A.A. A Code Yellow patient who not gone A Code Yellow patient who not gone
through the decontamination process.through the decontamination process.
B.B. A Code Green patient who is ambulatory A Code Green patient who is ambulatory and has not gone through the and has not gone through the decontamination process.decontamination process.
C.C. A Code Red patient who is deemed too A Code Red patient who is deemed too critical to go through the decontamination critical to go through the decontamination process.process.
D.D. A Code Red patient who has gone through A Code Red patient who has gone through litter decontamination in the Warm Zone.litter decontamination in the Warm Zone.
36. Which of the following patients 36. Which of the following patients could enter the area designated as the could enter the area designated as the
“cold zone”?“cold zone”?A.A. A Code Yellow patient who not gone through the A Code Yellow patient who not gone through the
decontamination process.decontamination process.……all must go through decontamination…all must go through decontamination…
B.B. A Code Green patient who is ambulatory and has A Code Green patient who is ambulatory and has not gone through the decontamination process.not gone through the decontamination process.all must go through decontamination…all must go through decontamination…
C.C. A Code Red patient who is deemed too critical to A Code Red patient who is deemed too critical to go through the decontamination process.go through the decontamination process.
D.D. A Code Red patient who has A Code Red patient who has gone through litter gone through litter decontamination in the Warm decontamination in the Warm Zone.Zone.
37.37. A train near the city’s high school has A train near the city’s high school has derailed and has spilled radioactive material derailed and has spilled radioactive material onto the roadways. The school nurse should onto the roadways. The school nurse should communicate which of the following communicate which of the following statements to the parents of the students?statements to the parents of the students?
A.A. The buses will not run this afternoon. The buses will not run this afternoon. Parents must arrange for alternate Parents must arrange for alternate transportation home for their children.transportation home for their children.
B.B. Parents are required to give verbal Parents are required to give verbal permission (over the phone) for their child to permission (over the phone) for their child to drive their vehicle home under these drive their vehicle home under these conditions.conditions.
C.C. The students will be kept at the High School The students will be kept at the High School until the local authorities declare the area as until the local authorities declare the area as being “all clear”.being “all clear”.
D.D. The students will be allowed to walk home as The students will be allowed to walk home as long as they avoid the contaminated area.long as they avoid the contaminated area.
37.37. A train near the city’s high school has A train near the city’s high school has derailed and has spilled radioactive material derailed and has spilled radioactive material onto the roadways. The school nurse should onto the roadways. The school nurse should communicate which of the following communicate which of the following statements to the parents of the students?statements to the parents of the students?
A.A. The buses will not run this afternoon. Parents The buses will not run this afternoon. Parents must arrange for alternate transportation home must arrange for alternate transportation home for their children.for their children.
B.B. Parents are required to give verbal permission Parents are required to give verbal permission (over the phone) for their child to drive their (over the phone) for their child to drive their vehicle home under these conditions.vehicle home under these conditions.
C.C. The students will be kept at the The students will be kept at the High School until the local High School until the local authorities declare the area as authorities declare the area as being “all clear”.being “all clear”.
D.D. The students will be allowed to walk home as The students will be allowed to walk home as long as they avoid the contaminated area.long as they avoid the contaminated area.
38.38. A triage nurse working in the Warm Zone at A triage nurse working in the Warm Zone at a hospital’s emergency room receives a a hospital’s emergency room receives a patient transported by ambulance from the patient transported by ambulance from the site of a chemical spill. What action should site of a chemical spill. What action should she take first?she take first?
A.A. Admit the patient to the main Admit the patient to the main section of the hospital’s emergency section of the hospital’s emergency room.room.
B.B. Determine the decontamination Determine the decontamination that occurred in the field.that occurred in the field.
C.C. Assess the patient.Assess the patient.
D.D. Administer oxygen via nasal Administer oxygen via nasal cannula. cannula.
38.38. A triage nurse working in the Warm Zone at A triage nurse working in the Warm Zone at a hospital’s emergency room receives a a hospital’s emergency room receives a patient transported by ambulance from the patient transported by ambulance from the site of a chemical spill. What action should site of a chemical spill. What action should she take first?she take first?
A.A. Admit the patient to the main section Admit the patient to the main section of the hospital’s emergency room.of the hospital’s emergency room.
B.B. Determine the Determine the decontamination that decontamination that occurred in the field.occurred in the field.
C.C. Assess the patient.Assess the patient.
D.D. Administer oxygen via nasal cannula. Administer oxygen via nasal cannula.
39.39. An 80-year old client recovering from An 80-year old client recovering from a CVA is being transferred to a skilled a CVA is being transferred to a skilled nursing facility. The nurse should nursing facility. The nurse should assign this client to which of the assign this client to which of the following staff members?following staff members?
A.A. A UAP who is about to graduate from a A UAP who is about to graduate from a baccalaureate nursing program.baccalaureate nursing program.
B.B. A certified nursing assistant with 10 A certified nursing assistant with 10 years experience.years experience.
C.C. A new graduate who passed the NCLEX A new graduate who passed the NCLEX last week.last week.
D.D. An LPN with 25 years experience at this An LPN with 25 years experience at this facility.facility.
39.39. An 80-year old client recovering from An 80-year old client recovering from a CVA is being transferred to a skilled a CVA is being transferred to a skilled nursing facility. The nurse should nursing facility. The nurse should assign this client to which of the assign this client to which of the following staff members?following staff members?
A.A. A UAP who is about to graduate from a A UAP who is about to graduate from a baccalaureate nursing program.baccalaureate nursing program.
B.B. A certified nursing assistant with 10 A certified nursing assistant with 10 years experience.years experience.
C.C. A new graduate who passed A new graduate who passed the NCLEX last week.the NCLEX last week.
D.D. An LPN with 25 years experience at this An LPN with 25 years experience at this facility.facility.
40.40. A patient tells you that he A patient tells you that he suspects that a nursing assistant suspects that a nursing assistant has stolen his watch. What action has stolen his watch. What action should you take?should you take?
A.A. Report the accusation to the hospital’s Report the accusation to the hospital’s public relations department.public relations department.
B.B. Watch the nursing assistant to see if Watch the nursing assistant to see if she’s wearing the watch. she’s wearing the watch.
C.C. Listen outside the break room door to the Listen outside the break room door to the nursing assistant’s conversation with her nursing assistant’s conversation with her friends to see if she incriminates herself.friends to see if she incriminates herself.
D.D. Report the accusation to your immediate Report the accusation to your immediate supervisor.supervisor.
40.40. A patient tells you that he A patient tells you that he suspects that a nursing assistant suspects that a nursing assistant has stolen his watch. What action has stolen his watch. What action should you take?should you take?
A.A. Report the accusation to the hospital’s Report the accusation to the hospital’s public relations department.public relations department.
B.B. Watch the nursing assistant to see if she’s Watch the nursing assistant to see if she’s wearing the watch. wearing the watch.
C.C. Listen outside the break room door to the Listen outside the break room door to the nursing assistant’s conversation with her nursing assistant’s conversation with her friends to see if she incriminates herself.friends to see if she incriminates herself.
D.D. Report the accusation to your Report the accusation to your immediate supervisor.immediate supervisor.
41.41. A man is prepared for discharge during A man is prepared for discharge during the 7-3 shift. He was admitted for the 7-3 shift. He was admitted for treatment of AIDS and Candida treatment of AIDS and Candida esophagitis. Who should be assigned esophagitis. Who should be assigned to care for this patient?to care for this patient?
A.A. The LPN who has worked on this unit for The LPN who has worked on this unit for 10 years.10 years.
B.B. The nursing assistant who has just The nursing assistant who has just completed an in-service on the special completed an in-service on the special needs of AIDS patients.needs of AIDS patients.
C.C. The RN who has 3 years experience on The RN who has 3 years experience on this nursing unit.this nursing unit.
D.D. The RN who was pulled to this unit from The RN who was pulled to this unit from the Cardiac ICU.the Cardiac ICU.
A.A. The LPN who has worked on this unit for 10 The LPN who has worked on this unit for 10 years.years.
B.B. The nursing assistant who has just The nursing assistant who has just completed an in-service on the special completed an in-service on the special needs of AIDS patients.needs of AIDS patients.
C.C. The RN who has 3 years The RN who has 3 years experience on this nursing experience on this nursing unit.unit.
D.D. The RN who was pulled to this unit from the The RN who was pulled to this unit from the Cardiac ICU.Cardiac ICU.
41.41. A man is prepared for discharge during A man is prepared for discharge during the 7-3 shift. He was admitted for the 7-3 shift. He was admitted for treatment of AIDS and Candida treatment of AIDS and Candida esophagitis. Who should be assigned esophagitis. Who should be assigned to care for this patient?to care for this patient?
42.42. Which area described below would Which area described below would be most ideal to serve as the “Cold be most ideal to serve as the “Cold Zone” in the Field after a chemical Zone” in the Field after a chemical incident?incident?
A.A. The parking lot immediately beside the The parking lot immediately beside the roadway where a truck carrying a chemical roadway where a truck carrying a chemical toxin has crashed.toxin has crashed.
B.B. The gym that is located 100 feet from the The gym that is located 100 feet from the location of the crash of a truck carrying a location of the crash of a truck carrying a chemical toxin, and is uphill and upwind of chemical toxin, and is uphill and upwind of the chemical incident.the chemical incident.
C.C. The main building of an elementary school, The main building of an elementary school, located over 300 feet from the outer located over 300 feet from the outer perimeter of the “Hot Zone”, and is uphill perimeter of the “Hot Zone”, and is uphill and upwind of the chemical incident.and upwind of the chemical incident.
D.D. The hospital emergency room. The hospital emergency room.
42.42. Which area described below would Which area described below would be most ideal to serve as the “Cold be most ideal to serve as the “Cold Zone” in the Field after a chemical Zone” in the Field after a chemical incident?incident?
A.A. The parking lot immediately beside the roadway The parking lot immediately beside the roadway where a truck carrying a chemical toxin has where a truck carrying a chemical toxin has crashed.crashed.
B.B. The gym that is located 100 feet from the location The gym that is located 100 feet from the location of the crash of a truck carrying a chemical toxin, of the crash of a truck carrying a chemical toxin, and is uphill and upwind of the chemical incident.and is uphill and upwind of the chemical incident.
C.C. The main building of an The main building of an elementary school, located over elementary school, located over 300 feet from the outer perimeter 300 feet from the outer perimeter of the “Hot Zone”, and is uphill of the “Hot Zone”, and is uphill and upwind of the chemical and upwind of the chemical incident.incident.
D.D. The hospital emergency room. The hospital emergency room.
In summary
Delegation:
•Teaching
•Assessment
•Specialized skills
PrioritizationPrioritization
Most acute basic needMost acute basic need Eliminate expected/usualEliminate expected/usual Pain is the answer ONLY if there is a Pain is the answer ONLY if there is a
sudden increase or it is unusual painsudden increase or it is unusual pain
TriageTriage
Red seen first…most acutely ill with Red seen first…most acutely ill with best chance of survival.best chance of survival.
In disaster select the answer that will In disaster select the answer that will do the most good for the most do the most good for the most people as your first course of actionpeople as your first course of action
African AmericanAfrican American
Head nodding does not always mean Head nodding does not always mean agreement.agreement.
Time orientation varies according to Time orientation varies according to age, socioeconomic subgroupage, socioeconomic subgroup
Elderly respected, large extended Elderly respected, large extended family is importantfamily is important
Religion source of strengthReligion source of strength
Asian AmericanAsian American
Silence valuedSilence valued Eye contact may be considered Eye contact may be considered
inappropriate inappropriate Head nodding does not always mean Head nodding does not always mean
agreementagreement Usually will not touch others during Usually will not touch others during
conversationconversation Head is considered sacredHead is considered sacred
European (white) origin European (white) origin AmericanAmerican
Silence can be respectful or Silence can be respectful or disrespectfuldisrespectful
Time is valuedTime is valued Man is dominant figureMan is dominant figure Tendency to be stoical when Tendency to be stoical when
expressing physical concernexpressing physical concern
Hispanic AmericanHispanic American
Avoiding eye contact with authority Avoiding eye contact with authority person indicates respectperson indicates respect
Dramatic body language is used to Dramatic body language is used to express emotions or painexpress emotions or pain
May place more value on relationship May place more value on relationship and events than being on timeand events than being on time
Extended family is highly regardedExtended family is highly regarded
Native AmericaNative America
Silence shows respectSilence shows respect Eye contact is viewed as Eye contact is viewed as
disrespectfuldisrespectful Personal space is importantPersonal space is important Elders are honoredElders are honored
43. The nurse is providing care to a Cuban 43. The nurse is providing care to a Cuban American client who is terminally ill. Numerous American client who is terminally ill. Numerous family members are present most of the time, and family members are present most of the time, and many of the family member are emotional. What is many of the family member are emotional. What is the most appropriate action?the most appropriate action?
1.1. Restrict the number of family members Restrict the number of family members visiting at one time.visiting at one time.
2.2. Inform the family that emotional outburst Inform the family that emotional outburst are to be avoided.are to be avoided.
3.3. Request permission to move the client to Request permission to move the client to a private room and allow the family to a private room and allow the family to visit.visit.
4.4. Contact the physician to speak to the Contact the physician to speak to the family regarding their behaviors.family regarding their behaviors.
43. The nurse is providing care to a Cuban 43. The nurse is providing care to a Cuban American client who is terminally ill. Numerous American client who is terminally ill. Numerous family members are present most of the time, and family members are present most of the time, and many of the family member are emotional. What is many of the family member are emotional. What is the most appropriate action?the most appropriate action?1.1. Restrict the number of family members Restrict the number of family members
visiting at one time.visiting at one time.2.2. Inform the family that emotional outburst Inform the family that emotional outburst
are to be avoided.are to be avoided.
3.3. Request permission to move Request permission to move the client to a private room and the client to a private room and allow the family to visit.allow the family to visit.
4.4. Contact the physician to speak to the Contact the physician to speak to the family regarding their behaviors.family regarding their behaviors.
44. The nurse is planning to instruct the Mexican 44. The nurse is planning to instruct the Mexican American client about nutrition and dietary American client about nutrition and dietary restrictions. What should the nurse be aware of in restrictions. What should the nurse be aware of in developing a plan for this ethnic group.developing a plan for this ethnic group.
1.1. Enjoys food that lacks color, flavor, Enjoys food that lacks color, flavor, and texture.and texture.
2.2. Primarily eats raw fish.Primarily eats raw fish.
3.3. Enjoys eating red meat.Enjoys eating red meat.
4.4. Views food as a primary form of Views food as a primary form of socialization.socialization.
44. The nurse is planning to instruct the Mexican 44. The nurse is planning to instruct the Mexican American client about nutrition and dietary American client about nutrition and dietary restrictions. What should the nurse be aware of in restrictions. What should the nurse be aware of in developing a plan for this ethnic group.developing a plan for this ethnic group.
1.1. Enjoys food that lacks color, flavor, Enjoys food that lacks color, flavor, and texture.and texture.
2.2. Primarily eats raw fish.Primarily eats raw fish.
3.3. Enjoys eating red meat.Enjoys eating red meat.
4.4. Views food as a primary Views food as a primary form of socialization.form of socialization.
45. Which of the following interventions is unlikely 45. Which of the following interventions is unlikely to facilitate effective communication between the to facilitate effective communication between the dying client and his or her family?dying client and his or her family?
1.1. The nurse encourages the client and family The nurse encourages the client and family to identify and discuss feelings openly.to identify and discuss feelings openly.
2.2. The nurse makes decisions for the client The nurse makes decisions for the client and family to relieve them of unnecessary and family to relieve them of unnecessary demands.demands.
3.3. The nurse assists the client and family in The nurse assists the client and family in carrying out spiritually meaningful carrying out spiritually meaningful practices.practices.
4.4. The nurse maintains a calm attitude and The nurse maintains a calm attitude and one of acceptance when the family or one of acceptance when the family or client expresses anger.client expresses anger.
45. Which of the following interventions is unlikely 45. Which of the following interventions is unlikely to facilitate effective communication between the to facilitate effective communication between the dying client and his or her family?dying client and his or her family?
1.1. The nurse encourages the client and family to The nurse encourages the client and family to identify and discuss feelings openly.identify and discuss feelings openly.
2.2. The nurse makes decisions for The nurse makes decisions for the client and family to relieve the client and family to relieve them of unnecessary demands.them of unnecessary demands.
3.3. The nurse assists the client and family in The nurse assists the client and family in carrying out spiritually meaningful practices.carrying out spiritually meaningful practices.
4.4. The nurse maintains a calm attitude and one The nurse maintains a calm attitude and one of acceptance when the family or client of acceptance when the family or client expresses anger.expresses anger.
46. Which of the following allows a client to provide 46. Which of the following allows a client to provide instructions to the physician regarding end of life instructions to the physician regarding end of life decisions?decisions?
1.1. Living WillLiving Will
2.2. Durable Power of Attorney for Durable Power of Attorney for HealthcareHealthcare
3.3. Substituted Decision affidavitSubstituted Decision affidavit
4.4. Do Not Resuscitate OrderDo Not Resuscitate Order
46. Which of the following allows a client to provide 46. Which of the following allows a client to provide instructions to the physician regarding end of life instructions to the physician regarding end of life decisions?decisions?
1.1. Living WillLiving Will2.2. Durable Power of Attorney for Durable Power of Attorney for
HealthcareHealthcare
3.3. Substituted Decision affidavitSubstituted Decision affidavit
4.4. Do Not Resuscitate OrderDo Not Resuscitate Order
47. Which of the following statements about 47. Which of the following statements about informed consent represents a need for an informed consent represents a need for an intervention by the nurse.intervention by the nurse.Select all that applySelect all that apply
1.1. ““I agree to surgery but now what is I agree to surgery but now what is going to be done.”going to be done.”
2.2. ““Whatever needs to be done just do it.”Whatever needs to be done just do it.”3.3. ““I consent to the surgery in spite of the I consent to the surgery in spite of the
risks.”risks.”4.4. ““My wife insists I have this surgery.”My wife insists I have this surgery.”5.5. ““This was a difficult decision but I had This was a difficult decision but I had
the information to make the decision.”the information to make the decision.”
47. Which of the following statements about 47. Which of the following statements about informed consent represents a need for an informed consent represents a need for an intervention by the nurse.intervention by the nurse.Select all that applySelect all that apply
1.1. ““I agree to surgery but now I agree to surgery but now what is going to be done.”what is going to be done.”
2.2. ““Whatever needs to be done Whatever needs to be done just do it.”just do it.”
3.3. ““I consent to the surgery in spite of the risks.”I consent to the surgery in spite of the risks.”
4.4. ““My wife insists I have this My wife insists I have this surgerysurgery.”.”
5.5. ““This was a difficult decision but I had the This was a difficult decision but I had the information to make the decision.”information to make the decision.”
48. The client has agreed to participate in a double-48. The client has agreed to participate in a double-blind study. Which statement indicates that the blind study. Which statement indicates that the client does not understand the study risks?client does not understand the study risks?
1.1. ““I can quit the study at any time.”I can quit the study at any time.”2.2. “ “ My personal health information will be My personal health information will be
protected during the study.”protected during the study.”3.3. ““The consent form identified the risks of The consent form identified the risks of
the study.”the study.”4.4. ““The researcher will tell be what The researcher will tell be what
medication I am receiving.”medication I am receiving.”
48. The client has agreed to participate in a double-48. The client has agreed to participate in a double-blind study. Which statement indicates that the blind study. Which statement indicates that the client does not understand the study risks?client does not understand the study risks?
1.1. ““I can quit the study at any time.”I can quit the study at any time.”2.2. “ “ My personal health information will be My personal health information will be
protected during the study.”protected during the study.”3.3. ““The consent form identified the risks of The consent form identified the risks of
the study.”the study.”
4.4. ““The researcher will tell be The researcher will tell be what medication I am what medication I am receiving.”receiving.”