They must be reviewed and re-signed every 10 years in order to remain valid.

Safe and effective care environment

• Which of these is true regarding advance directives?

1.They cannot be honored by EMTs (emergency medical technicians) unless signed by a doctor.

2.An advanced directive is legally valid in every state, no matter which state it was created in.

3.A physician must determine when a patient is unable to make medical decisions for himself.

4.They must be reviewed and re-signed every 10 years in order to remain valid.They cannot be honored by EMTs (emergency medical technicians) unless signed by a doctor.Which of the following tasks can be delegated to a UAP (unlicensed assistive personnel)? 1. Ambulating a patient three days post-op appendectomy in the hallway. 2. Nasotracheal suctioning of a patient for the first time. 3. Irrigating a nasogastric tube. 4. Setting up a PCA (patient-controlled analgesia) pump.Ambulating the patient three days post-op with no mentioned complications is absolutely appropriate. The other tasks fall under the delegation of an RN or LPN.The LPN (licensed practical nurse) observes nursing care administered by a UAP (unlicensed assistive personnel).Which of the following actions, if noted by the LPN, would require further teaching? 1. The UAP places the eye shield of a patient with Bell’s palsy on the bedside table and turns out the lights so that the patient can nap.

 2. The UAP administers a bed bath to a comatose patient with the help of another UAP. 3. The UAP ambulates a patient two days post-hysterectomy. 4. The UAP gives a blanket to a patient who complains she is cold.The eye shield of a Bell’s palsy patient must be worn in sleep to protect the eye against damage. Remember, a Bell’s palsy patient has a side of the face with no sensation- it could be dangerous for them to roll over in their sleep onto this side.Which of the following situations is an example of negligence? 1. The nurse observes a UAP enter the room of a patient on contact precautions wearing gloves and a gown. 2. The nurse checks the distal pulses of a patient’s legs two hours after they have returned from a cardiac catheterization. 3. A nurse transcribes a new medication order: Questran powder 2 oz bid with wet food or one full glass of water. 4. The UAP (Unlicensed Assistive Personnel) fills a water basin with warm water while the patient with depression combs her hair.The nurse should have checked the patient’s distal pulse immediately after the cardiac catheterization.A nurse’s aide comes to the nurse and expresses concerns about a patient’s T-tube. The aide says, “I’m kind of worried because it’s drained 700mL over the course of our shift. That’s a lot!” Which of the following responses does the nurse give to the aide? 1. “That is a normal amount of drainage for a T-tube because this is his first day after surgery.”  2. “That is a normal amount of drainage for a T-tube because this is his fifth day after surgery.”  3. “That is an excessive amount of drainage for a T-tube. I will further assess the patient.”  4. “That is a small amount of drainage for a T-tube. Once I had a patient who drained 2,000mL in one shift!” That is normal amount because it is the first day First day post-op, a T-tube can drain anywhere between 500mL to 1000mL. After the first day, it decreases and eventually tapers off.The nurse receives a report on the medical/surgical unit. Which of the following clients should the nurse see FIRST? 1. A client six hours after a hysterectomy complaining of nausea. 2. A client diagnosed with peptic ulcer disease who is scheduled for stomach surgery in two hours.

 3. A client two hours after a cast was put on his left arm complaining his arm feels “funny.”  4. A client with a respiratory rate of 24 and an oxygen saturation of 93%.Correct Complaining of nausea after a hysterectomy is a potential problem, not a current one. On the other hand, an arm in a cast that “feels funny” is related to impaired circulation and needs immediate assessment. The client with the O2 saturation of 93% may sound tempting to pick, but no where does it indicate that the client is in The charge nurse works with two LPNs (licensed practical nurses) and one UAP (unlicensed assistive personnel).Which of the following assignments, if selected for the UAP, would be considered appropriate? 1. A patient with new onset seizures needs assistance to the bathroom. 2. A terminal cancer patient is being transferred to hospice home care. 3. A patient rings the call bell and asks for a Tylenol. 4. A patient two days post-op cholecystectomy requires a sterile dressing change.Incorrect This patient needs basic ADLs care. The LPN can do the sterile dressing change. Only RNs can do discharge teaching (like transfers) or assess pain.The charge nurse implements a change in the nursing assistant’s job description. The change increases the nursing assistant’s responsibilities. A nurse with 20 years of service on the unit verbally agrees to the change, but her behaviors indicate otherwise. Which of the following actions by the charge nurse is MOST appropriate? 1. Schedule an appointment to speak with the nurse in private. 2. Enable an open discussion during a prescheduled meeting. 3. Ask the nursing assistants to accommodate the nurse. 4. Inform the charge nurse that you have observed her verbal agreement differs from her behavior.Correct enable an open- end discussion during a prescheduled meeting Do not directly confront the nurse or ask anyone to accommodate her. Instead, use a meeting to bring up the issue and allow her peers to speak positively about the change. Peer pressure can be an effective tool.The nurse cares for children at a daycare. On a hot summer day, four children return from recess with various complaints. Which of the following children should the nurse see FIRST? 1. A child diagnosed with leukemia was stung by a bee and is complaining of feeling hot and itchy all over.

 2. A child with asthma is complaining of dizziness and a sore throat. 3. A child diagnosed with type one diabetes is sweaty, pale, and complains of shakiness. 4. A child diagnosed with hemophilia says she has a headache and has slurred speech.Correct This patient is beginning to experience anaphylactic shock and needs emergency treatment. The others also need treatment, but are more potential problems than immediate ones.The nursing team includes two RNs, one LPN, a nursing assistant, and a nurse reassigned from the postpartum unit.The nurse should consider the assignments appropriate if the reassigned nurse cares for which of the following patients? 1. A client diagnosed with a head injury and a Glasgow coma scale of 5. 2. A client with a spinal cord injury requiring assistance with meals. 3. A client diagnosed with a myocardial infarction complaining of burning on urination. 4. A client diagnosed with COPD who displays Cheyne-Stokes respirations..The reassigned nurse can care for the patient with the UTI. Remember, reassigned nurses need stable patients.A client diagnosed with myocardial infarction complaining of burning of urination The nurse in an emergency room receives a call from an ambulance alerting that a bomb has gone off in a nearby shopping center and a minimum of forty victims will be arriving shortly for medical care. What action should the nurse take NEXT? 1. Alert the nursing supervisor. 2. Prepare enough stretchers to accommodate overflow. 3. Alert the rest of the ER nurses that they will be working mandatory double shifts. 4. Tell the ambulance crew to take half the victims to the next-nearest hospital.Alert the nursing supervisor. There is most likely a disaster plan in place, which must be implemented by the nursing supervisor. The ER nurse must go up the chain of command to resolve this issue.A patient is diagnosed with a DVT. Which of the following, if stated by a UAP (Unlicensed Assistive Personnel), requires intervention by the nurse? 1. “The patient states that her leg is warm, swollen, and painful.”