Transcript Applying Principles Associated with Delegation and Disaster Nursing

Safe and Effective Care/Disaster:
Cultural Diversity, Ethical/Legal
Delegation & Disaster Issues in
Nursing
Created by Professor Jill Ray
Revised by Professor Brenda Rowe
What tasks can an RN Delegate?
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Who is she delegating the task to?
What type education/experience does that
individual have?
Is there something about the task that
requires the skill/knowledge of an RN?
Is there something about the task that
requires the skill/knowledge of a
specialized RN?
The person to whom the task is
delegated must have the
education and the experience
required to complete the task
safely and effectively.
When would a task be
considered routine…when
should a “routine” task be
completed by an RN?
1. The nursing team consists of 2 RNs and 1 LPN.
The assignments would be considered appropriate
if the LPN were assigned to which of the following
patients?
A 3 year old who had an open reduction of a
fractured radius performed yesterday.
B. A 5 year old who had a tonsillectomy
yesterday.
C. A 7 year old who is being monitored for a
seizure disorder.
D. A 2 year old who is receiving a tube feeding
via a gastrostomy tube.
A.
1. The nursing team consists of 2 RNs and 1 LPN.
The assignments would be considered appropriate
if the LPN were assigned to which of the following
patients?
A.
B.
C.
A 3 year old who had an open reduction of a fractured
radius performed yesterday.
A 5 year old who had a tonsillectomy yesterday.
A 7 year old who is being monitored for a seizure
disorder.
D. A 2 year old who is receiving a tube
feeding via a gastrostomy tube.
…Routine task…within her scope of
practice.
Tasks that can be delegated to an
LPN/LVN
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Any “regular” procedure that does not require
assessment , teaching, or nursing judgment.
The technical “doer”
Physical care of clients with more complex
conditions, selected treatments, and perhaps
some medications.
Must be supervised by an RN.
Sterile dressing change OK
2. A client is admitted to ICU bed 3 with a
diagnosis of acute GI bleed. Which of
the following actions is BEST for the RN
to take?
Ask the UAP to obtain v/s while the RN obtains
orders from the MD.
B. Ask the LPN to assess peripheral pulses while
the RN assesses breath sounds.
C. Ask the UAP to obtain equipment needed for
the patient’s care while the RN assesses the
patient.
D. Ask the LPN to assess the patient while the RN
reviews orders with the MD.
A.
2. A client is admitted to ICU bed 3 with a
diagnosis of acute GI bleed. Which of
the following actions is BEST for the RN
to take?
A.
B.
Ask the UAP to obtain v/s while the RN obtains orders
from the MD. Initial v/s
Ask the LPN to assess peripheral pulses while the RN
assesses breath sounds. Assessment
C. Ask the UAP to obtain equipment
needed for the patient’s care while
the RN assesses the patient.
D.
Ask the LPN to assess the patient while the RN reviews
orders with the MD. Assessment
What can be delegated to a nursing
assistant or a UAP?
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Routine, unchanging procedures
Assist with direct patient care activities
under the supervision of an RN
Scope of nursing practice is limited.
How do we prioritize tasks?
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Maslow’s Hierarchy of
Needs
Basic needs must be
met first
Pain is considered a
psychosocial need
Deal with most acute
actual need first…
3. The RN who is caring for clients in the
oncology clinic, receives four phone
messages. Which call should she return
first?
A client who is 5 days postop prostatectomy
who complains of chills and a burning
sensation with urination.
B. A client who is receiving chemotherapy who is
experiencing fatigue.
C. A client newly diagnosed with colon cancer
whose stool specimen tested positive for
blood.
D. A client receiving chemotherapy for lung
cancer who is experiencing a loss of appetite.
A.
3. The RN who is caring for clients in the
oncology clinic, receives four phone
messages. Which call should she return
first?
A. A client who is 5 days postop
prostatectomy who complains of chills
and a burning sensation with urination.
…Most acute…
B.
C.
D.
A client who is receiving chemotherapy who is
experiencing fatigue.
A client newly diagnosed with colon cancer whose
stool specimen tested positive for blood.
A client receiving chemotherapy for lung cancer who is
experiencing a loss of appetite.
4. A nurse from the oncology unit has been
pulled to the pediatric unit. Which of the
following patient assignments would be
BEST for this RN?
A. A newborn newly admitted with fever of
unknown origin.
B. A 10-year old who 4 days post operative
appendectomy.
C. A 5-year old newly diagnosed with
diabetes.
D. A 12-year old newly diagnosed with a
seizure disorder.
4. A nurse from the oncology unit has been
pulled to the pediatric unit. Which of the
following patient assignments would be
BEST for this RN?
A.
A newborn newly admitted with fever of
unknown origin. …Ped. specialty…
B. A 10-year old who 4 days post
operative appendectomy.
C.
A 5-year old newly diagnosed with diabetes.
..teaching…
D. A 12-year old newly diagnosed with a seizure
disorder. ..teaching…
5. The RN cares for patients on a medicalsurgical nursing unit. Which of the following
patients should the RN see FIRST?
A 91-year old patient who is 72 hours postop
colon resection who has a temperature of 100
degrees F.
B. A 24-year old patient admitted to rule out
ectopic pregnancy, whose BP is 90/58, HR 101.
C. A 45-year old patient who was admitted 24
hours ago with a diagnosis of r/o MI whose HR
is 72, BP is 145/80.
D. A 50-year old male patient admitted with high
blood pressure who is complaining of back
pain.
A.
5. The RN cares for patients on a medicalsurgical nursing unit. Which of the following
patients should the RN see FIRST?
A.
A 91-year old patient who is 72 hours postop colon
resection who has a temperature of 100 degrees F.
B. A 24-year old patient admitted to
rule out ectopic pregnancy, whose
BP is 90/58, HR 101….most acute…
C.
D.
A 45-year old patient who was admitted 24 hours ago
with a diagnosis of r/o MI whose HR is 72, BP is
145/80.
A 50-year old male patient admitted with high blood
pressure who is complaining of back pain.
6.
An adult has been medicated for her surgery.
The operating room (OR) nurse, when going
through the client’s chart, realizes that the consent
form has not been signed. Which of the following
is the BEST action for the nurse to take?
A. Assume it is emergency surgery and the
consent is implied.
B. Get the consent form and have the client
sign it.
C. Tell the MD that the consent form is not
signed.
D. Have a family member sign the consent
form.
6.
An adult has been medicated for her surgery.
The operating room (OR) nurse, when going
through the client’s chart, realizes that the consent
form has not been signed. Which of the following
is the BEST action for the nurse to take?
Assume it is emergency surgery and the
consent is implied.
B. Get the consent form and have the client sign
it.
A.
C. Tell the MD that the consent
form is not signed.
D. Have a family member sign the consent form.
7. Which of the following tasks could
not be delegated to a UAP?
A patient with a fractured wrist who needs
assistance completing her menu for the next
day.
B. A patient with left-sided weakness who needs
assistance to get out of bed to the bedside
commode.
C. A preop patient who needs assistance learning
to use the incentive Spiro meter.
D. A patient who is being started on Aldomet and
needs his blood pressure checked every 4
hours.
A.
7. Which of the following tasks could
not be delegated to a UAP?
A.
B.
A patient with a fractured wrist who needs assistance
completing her menu for the next day.
A patient with left-sided weakness who needs
assistance to get out of bed to the bedside commode.
C. A preop patient who needs
assistance learning to use the
incentive Spiro meter….teaching…
D.
A patient who is being started on Aldomet and needs
his blood pressure checked every 4 hours. …not the
baseline BP – this is just routine
monitoring…pts are started on Aldomet
at the MD’s office and allowed to go
home to monitor BP…
8. Which of the following clients should
the nurse deal with first?
A. A client who needs her dressing
changed.
B. A client who needs his endotracheal tube
suctioned.
C. A client who needs to be medicated for
pain.
D. A client who is incontinent and needs to
be cleaned.
8. Which of the following clients should
the nurse deal with first?
A.
A client who needs her dressing changed.
B. A client who needs his
endotracheal tube
suctioned….ABC’s…
A client who needs to be medicated for pain.
D. A client who is incontinent and needs to be
cleaned.
C.
9. Which of the following clients should
the nurse observe first?
A. A client who has just returned from the
OR
B. A client whose call light is not working
C. A client with Alzheimer’s disease
D. A client who is receiving a heating pad
treatment.
9. Which of the following clients should
the nurse observe first?
A. A client who has just
returned from the OR…most
acute, requires assessment…
B. A client whose call light is not working
C. A client with Alzheimer’s disease
D. A client who is receiving a heating pad
treatment.
10. Four clients have signaled with their
call bells for the nurse. Who should be seen
first?
A. A client who needs to use the toilet.
B. A client who does not have his glasses or
hearing aid.
C. A client who has just been given
morphine.
D. A client in a Geri chair with a restraint
vest on.
10. Four clients have signaled with their
call bells for the nurse. Who should be seen
first?
A. A client who needs to use the toilet.
B. A client who does not have his glasses or
hearing aid.
C. A client who has just been
given morphine… most acute
D. A client in a Geri chair with a restraint
vest on.
11. A nursing team consists of an RN, two
LPNs, and an UAP. Which of the following
patients should be assigned to the RN?
A 3 year old recovering from a gunshot wound
to the abdomen that requires a dressing
change.
B. A 1 year old who is receiving tube feedings via
a nasogastric tube.
C. A 6 year old with cystic fibrosis who requires
chest physiotherapy qid.
D. A 5 year who has been newly diagnosed with
diabetes.
A.
11. A nursing team consists of an RN, two
LPNs, and an UAP. Which of the following
patients should be assigned to the RN?
A 3 year old recovering from a gunshot wound
to the abdomen that requires a dressing
change.
B. A 1 year old who is receiving tube feedings via
a nasogastric tube.
C. A 6 year old with cystic fibrosis who requires
chest physiotherapy qid.
A.
D. A 5 year who has been newly
diagnosed with diabetes.
…teaching…
Don’t forget the basic principles of
safety…
12. The nurse enters the dayroom and
finds a fire. Which is the best initial action?
Evacuate any people in the room, beginning
with the most ambulatory and ending with the
least mobile.
B. Activate the fire alarm or call the operator,
depending on the institution’s system.
C. Get a fire extinguisher and put out the fire.
D. Close all the windows and doors, and turn off
any oxygen or electrical appliances.
A.
12. The nurse enters the dayroom and
finds a fire. Which is the best initial action?
A. Evacuate any people in the room,
beginning with the most
ambulatory and ending with the
least mobile….Rescue, Activate,
Confine, Extinguish …
B.
C.
D.
Activate the fire alarm or call the operator, depending
on the institution’s system.
Get a fire extinguisher and put out the fire.
Close all the windows and doors, and turn off any
oxygen or electrical appliances.
13. The patient reports to you that he noticed
that $20.00 was missing from his bedside table
after the Respiratory Therapist finished his
treatment. What action should you take?
Ask the Respiratory Therapist if he knows
anything about the missing money.
B. Report the missing money to the head of the
Respiratory Therapy department.
C. Report the missing money to your immediate
supervisor.
D. Record the missing money in the nurses’ notes
– the MD will follow up when he reads your
note later in the day.
A.
13. The patient reports to you that he noticed
that $20.00 was missing from his bedside table
after the Respiratory Therapist finished his
treatment. What action should you take?
Ask the Respiratory Therapist if he knows
anything about the missing money.
B. Report the missing money to the head of the
Respiratory Therapy department.
A.
C. Report the missing money to
your immediate supervisor…
chain of command …
D. Record the missing money in the nurses’ notes
– the MD will follow up when he reads your
note later in the day.
Chain of Command
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Always report to the RN in the scenario’s
immediate supervisor.
14.
An adult has just arrived on the unit after
surgery. Which of the following is the most
appropriate task for the nurse to delegate to the
certified nursing assistant (CNA)?
Assessment of the vital signs while the RN
watches.
B. Suctioning the tracheotomy and reporting back
to the nurse.
C. Changing the client’s postoperative dressing
and then describing it to the RN.
D. Measure the amount of urine in the Urinary
Drainage Bag.
A.
14.
An adult has just arrived on the unit after
surgery. Which of the following is the most
appropriate task for the nurse to delegate to the
certified nursing assistant (CNA)?
Assessment of the vital signs while the RN
watches.
B. Suctioning the tracheotomy and reporting back
to the nurse.
C. Changing the client’s postoperative dressing
and then describing it to the RN.
A.
D. Measure the amount of urine in
the Urinary Drainage Bag.
15. The nurse is making the assignment for
the floor. There is one LPN and three RNs.
Which of the following clients should the LPN
be assigned to care for?
A client who is intubated and a newly
diagnosed diabetic.
B. A recent ICU transfer and a person with AIDS.
C. A client awaiting a nursing home bed and a
client one day post-hernia repair.
D. A new admission for cholecystectomy and a
client one day post-op mastectomy.
A.
15. The nurse is making the assignment for
the floor. There is one LPN and three RNs.
Which of the following clients should the LPN
be assigned to care for?
A client who is intubated and a newly
diagnosed diabetic.
B. A recent ICU transfer and a person with AIDS.
A.
C. A client awaiting a nursing
home bed and a client one day
post-hernia repair. … least acute…
D. A new admission for cholecystectomy and a
client one day post-op mastectomy.
16. The nurse is unfamiliar with a new
piece of OR equipment that is scheduled to
be used today. What is the best course of
action?
A. Ask another nurse for instructions on
how to use it.
B. Wait until she has attended a class on
using the equipment before using it.
C. Get another nurse who is familiar with
the equipment to operate it.
D. Read the instructions provided with the
equipment.
16. The nurse is unfamiliar with a new
piece of OR equipment that is
scheduled to be used today. What is
the best course of action?
A.
B.
Ask another nurse for instructions on how to use it.
Wait until she has attended a class on using the
equipment before using it… should do this –
but what happens today?...
C. Get another nurse who is familiar
with the equipment to operate it.
D.
Read the instructions provided with the equipment.
16. The nurse is unfamiliar with a new
piece of OR equipment that is
scheduled to be used today. What is
the best course of action?
A.
B.
Ask another nurse for instructions on how to use it.
Wait until she has attended a class on using the
equipment before using it… should do this –
but what happens today?...
C. Get another nurse who is familiar
with the equipment to operate it.
D.
Read the instructions provided with the equipment.
•Confused
•Unsure of how
to do something
•Unsure of how
something works
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Never attempt a task you have not been
trained to do
Always follow manufacturer's guidelines
17.
An adult has developed a stage II pressure
ulcer. He is scheduled to receive wet to dry
dressings every shift. Which of the following team
members would be the BEST choice to perform
this task?
An LPN who has worked on the nursing unit
for 6 months.
B. A UAP who will graduate from a baccalaureate
nursing program in 10 days.
C. A nursing assistant with 10 years experience
on this nursing unit.
D. An LPN from the Surgical ICU who has been
pulled to the nursing unit to help out today.
A.
17.
An adult has developed a stage II pressure
ulcer. He is scheduled to receive wet to dry
dressings every shift. Which of the following team
members would be the BEST choice to perform
this task?
A. An LPN who has worked on the
nursing unit for 6 months.
A UAP who will graduate from a baccalaureate
nursing program in 10 days.
C. A nursing assistant with 10 years experience
on this nursing unit.
D. An LPN who has been pulled to the nursing
unit to help out today.
B.
18. The nurse is about to administer the
premedication prescribed for a woman
scheduled for a lumpectomy. The client
says, “I’ll be glad when the surgery is over.
It will eliminate all the cancer from my
body.” Which of the following is the BEST
action for the nurse to take?
A. Medicate the client and tell the MD.
B. Correct the client’s misconceptions.
C. Call the MD without medicating the
client.
D. Give the medications to the client and
note her comment in the chart
18. The nurse is about to administer the
premedication prescribed for a woman
scheduled for a lumpectomy. The client
says, “I’ll be glad when the surgery is over.
It will eliminate all the cancer from my
body.” Which of the following is the BEST
action for the nurse to take?
A. Medicate the client and tell the MD.
B. Correct the client’s misconceptions.
C. Call the MD without
medicating the client.
D. Give the medications to the client and
note her comment in the chart
19.
The nursing team, consisting of one RN, one
LPN, and one nursing assistant has just
received report from the previous shift. At
the completion of the report, what action
should the RN take FIRST?
Make assignments for the members of the
nursing team.
B. Assess each patient that will be cared for by
the nursing team.
C. Assess a patient who complains that the PCA
has suddenly stopped controlling his postop
pain.
D. Assess a patient who is requesting his
prescribed prn for pain.
A.
19.
A.
B.
The nursing team, consisting of one RN, one
LPN, and one nursing assistant has just
received report from the previous shift. At
the completion of the report, what action
should the RN take FIRST?
Make assignments for the members of the nursing
team.
Assess each patient that will be cared for by the
nursing team.
C. Assess a patient who complains that
the PCA has suddenly stopped
controlling his postop pain.
D.
Assess a patient who is requesting his prescribed prn
for pain.
20. An RN who works in labor and delivery has been
pulled to a medical nursing unit that specializes in
diabetes to assist with patient care during the 7-3
shift. Which of the following patient assignments
would be appropriate for this RN?
A. A patient who is on an insulin drip.
B. A patient with a new diagnosis of
diabetes.
C. A patient who has received an insulin
pump and is being prepared for
discharge.
D. A patient who is being treated for high
blood pressure.
20. An RN who works in labor and delivery has been
pulled to a medical nursing unit that specializes in
diabetes to assist with patient care during the 7-3
shift. Which of the following patient assignments
would be appropriate for this RN?
A patient who is on an insulin drip.
B. A patient with a new diagnosis of diabetes.
C. A patient who has received an insulin pump
and is being prepared for discharge.
A.
D. A patient who is being treated
for high blood pressure.
21. The nurse evaluates assignments on a
medical/surgical unit. The assignments are
deemed appropriate if a nursing assistant
performs which of the following tasks?
A. Admission vital signs for a patient who is
scheduled for surgery tomorrow.
B. Before lunch accucheck for a patient who
is receiving hyperalimentation fluids.
C. A dressing change for a client with a
pressure ulcer.
D. Discharge teaching for a client diagnosed
with COPD.
21. The nurse evaluates assignments on a
medical/surgical unit. The assignments are
deemed appropriate if a nursing assistant
performs which of the following tasks?
A.
Admission vital signs for a patient who is
scheduled for surgery tomorrow.
B. Before lunch accucheck for a
patient who is receiving
hyperalimentation fluids…not a
new HAF administration…
A dressing change for a client with a pressure
ulcer.
D. Discharge teaching for a client diagnosed with
COPD.
C.
22. The nursing team consists of one RN,
one LPN, and one nursing assistant. Which
of the following patients should the RN
attend to FIRST?
A patient who is experiencing dysuria after a
cystoscope.
B. A patient whose BP has changed from 160/82
to 92/75.
C. A patient who is experiencing incisional pain 24
hours postop cholecystectomy.
D. A patient who is visually impaired who needs
assistance to get OOB to the bedside
commode.
A.
22. The nursing team consists of one RN,
one LPN, and one nursing assistant. Which
of the following patients should the RN
attend to FIRST?
A.
A patient who is experiencing dysuria after a
cystoscope.
B. A patient whose BP has
changed from 160/82 to 92/75.
A patient who is experiencing incisional pain 24
hours postop cholecystectomy.
D. A patient who is visually impaired who needs
assistance to get OOB to the bedside
commode.
C.
23. Mr. Smith in RM 412 has a living will.
The RN should consult this document prior
to the implementation of which of the
following MD orders?
A. Turn, cough, deep breath q 2hours while
awake.
B. Osmolite 500ml QID via PEG tube.
C. OOB QID to bedside chair.
D. Active ROM exercises QID.
23. Mr. Smith in RM 412 has a living will.
The RN should consult this document prior
to the implementation of which of the
following MD orders?
A. Turn, cough, deep breath q 2hours while
awake.
B. Osmolite 500ml QID via PEG
tube. …life sustaining tx…
C. OOB QID to bedside chair.
D. Active ROM exercises QID.
24. Which phone call should the RN
return first?
A patient who is 5 days postop hysterectomy
who is complaining of severe abdominal pain.
B. A patient receiving chemotherapy who is
complaining of discomfort secondary to oral
lesions.
C. A patient 2 days postop Laparoscopic
Cholecystectomy who is complaining of
abdominal distention.
D. A dialysis patient who complains of dry, itchy
skin.
A.
24. Which phone call should the RN
return first?
A. A patient who is 5 days postop
hysterectomy who is complaining of
severe abdominal pain.
B.
C.
D.
A patient receiving chemotherapy who is complaining
of discomfort secondary to oral lesions.
A patient 2 days postop Laparoscopic Cholecystectomy
who is complaining of abdominal distention.
A dialysis patient who complains of dry, itchy skin.
25. The nurse instructs the nursing assistant to
assist her in obtaining output measurements
for a patient receiving Lasix. There would be
cause for concern if the instructions given to
the nursing student included which of the
following:
A. Empty the urinary drainage bag into the
measuring device kept in the patient’s
bathroom.
B. Palpate the patient’s abdomen to determine if
his bladder is empty.
C. Milk the urine in the drainage tubing into the
urinary drainage bag prior to emptying the
bag.
D. Report back to me with a description of the
color and amount of urine
25. The nurse instructs the nursing assistant to assist
her in obtaining output measurements for a
patient receiving Lasix. There would be cause for
concern if the instructions given to the nursing
student included which of the following:
A.
Empty the urinary drainage bag into the measuring
device kept in the patient’s bathroom.
B. Palpate the patient’s abdomen to
determine if his bladder is empty.
C.
D.
Milk the urine in the drainage tubing into the urinary
drainage bag prior to emptying the bag.
Report back to me with a description of the color and
amount of urine
26. A male UAP complains to the RN that
another RN on the unit often slaps him on
the buttocks. What action should the RN
take?
Report the complaint to her immediate
supervisor.
B. Discuss the complaint with the other RN.
C. Ensure that in the future that assignments are
made in such a way that these two individuals
will not be working with each other.
D. Complete an incident report about this
complaint.
A.
26. A male UAP complains to the RN that
another RN on the unit often slaps him
on the buttocks. What action should
the RN take?
A. Report the complaint to her
immediate supervisor.
Discuss the complaint with the other RN.
C. Ensure that in the future that assignments are
made in such a way that these two individuals
will not be working with each other.
D. Complete an incident report about this
complaint.
B.
27. An RN from the ICU is pulled to the
oncology unit. Which assignment is
most appropriate for this RN to take?
A. A 45-year old after a colon resection.
B. A 92-year old comatose patient in the
terminal stages of gastric cancer.
C. A 21-year old receiving 5FU IV.
D. A 65-year old with a positive prostate
biopsy.
27. An RN from the ICU is pulled to the
oncology unit. Which assignment is
most appropriate for this RN to take?
A. A 45-year old after a colon
resection.
B. A 92-year old comatose patient in the
terminal stages of gastric cancer.
C. A 21-year old receiving 5FU IV.
D. A 65-year old with a positive prostate
biopsy.
28. A bomb has just exploded at a local
school. What would be the MOST
appropriate action for an RN with 20
years experience on a medical-surgical
nursing unit to take?
Drive immediately to the site of the disaster
and begin working with victims inside the
building.
B. Contact all the RNs she knows who live within
5 miles of the school to encourage them to go
to the site and begin assisting victims.
C. Contact the closest hospital to the disaster and
volunteer her services.
D. Drive immediately to the school to assist
distraught parents.
A.
28. A bomb has just exploded at a local
school. What would be the MOST
appropriate action for an RN with 20
years experience on a medical-surgical
nursing unit to take?
A.
B.
Drive immediately to the site of the disaster and begin
working with victims inside the building.
Contact all the RNs she knows who live within 5 miles
of the school to encourage them to go to the site and
begin assisting victims.
C. Contact the closest hospital to the
disaster and volunteer her services.
D.
Drive immediately to the school to assist distraught
parents.
What is meant by the term
Triage?
29. The following represents the categories
that can be used to assist with triage of
disaster victims. Which category would be
seen first?
A. Yellow
B. Green
C. Red
D. Black
29. The following represents the categories
that can be used to assist with triage of
disaster victims. Which category would
be seen first?
A. Yellow
B. Green
C. Red
D. Black
Red: Immediate Care. Class I. Critical, life
threatening. Compromised airway, shock,
hemorrhage
Yellow: Minimal Care. Urgent. Class II. Major
illness or injury. Requires treatment within 20
minutes to 2 hours. Open fracture. Chest
wound.
Green: Delayed Care. Class III. Care may be
delayed 2 hours or more. Minor injuries;
walking wounded, closed fracture, sprain, strain.
Black: Expectant Care. Class IV. Dead or
expected to die. Massive head injury. Extensive
full-thickness burns.
30. The RN at the Home Nursing agency
receives messages from four of her patients.
Which patient should she contact FIRST?
A. 45 year old patient with Bronchitis who
has been experiencing vomiting and
diarrhea for 24 hours.
B. 51 year old patient with Diabetes whose
AM blood sugar was 175.
C. 49 year old patient with peripheral
vascular disease who complains of “cold
feet”.
D. 55 year old patient with essential
hypertension who experiences “lightheadedness” when he stands up.
30. The RN at the Home Nursing agency
receives messages from four of her patients.
Which patient should she contact FIRST?
A. 45 year old patient with
Bronchitis who has been
experiencing vomiting and
diarrhea for 24 hours.
51 year old patient with Diabetes whose AM
blood sugar was 175.
C. 49 year old patient with peripheral vascular
disease who complains of “cold feet”.
D. 55 year old patient with essential hypertension
who experiences “light-headedness” when he
stands up.
B.
31. The RN in an Emergency Department has
been asked to use the California Fire Chiefs
Association Victim triage tag system. Which
of the following individuals would be
classified in the “Green” category:
A patient who is conscious and has sustained
an opened fracture of the femur.
B. A patient who is conscious and does not
appear to have any injuries of any type.
C. A patient who is conscious and has sustained
multiple scrapes and bruising of the face and
upper body.
D. A patient who is unconscious and has an open
skull fracture.
A.
31. The RN in an Emergency Department has
been asked to use the California Fire Chiefs
Association Victim triage tag system. Which
of the following individuals would be
classified in the “Green” category:
A patient who is conscious and has sustained
an opened fracture of the femur. …Yellow..
B. A patient who is conscious and does not
appear to have any injuries of any type.
C. A patient who is conscious and has
A.
sustained multiple scrapes and
bruising of the face and upper body.
D. A patient who is unconscious and has an open
skull fracture. …red/black…
32. The patient the RN is assessing at the
scene of a disaster has full thickness burns
that cover 90 percent of his body. What
classification would he be given?
A. Red
B. Yellow
C. Green
D. Black
32. The patient the RN is assessing at the
scene of a disaster has full thickness burns
that cover 90 percent of his body. What
classification would he be given?
A. Red
B. Yellow
C. Green
D. Black
33. After receiving report from the 11-7
shift nurse, which of the following should
the nurse see first?
A 40-year old client who had gastric bypass
surgery yesterday.
B. A 21 year-old who has suddenly developed
wheezes.
C. A 75 year old client with left-sided weakness
who is requesting assistance to the bedside
commode.
D. A 32-year old who is refusing her morning
dose of Lasix.
A.
33. After receiving report from the 11-7
shift nurse, which of the following should
the nurse see first?
A.
A 40-year old client who had gastric bypass
surgery yesterday.
B. A 21 year-old who has suddenly
developed wheezes.
A 75 year old client with left-sided weakness
who is requesting assistance to the bedside
commode.
D. A 32-year old who is refusing her morning
dose of Lasix.
C.
Chemical Incidents
34. Triage in the field for chemical incidents are divided
into the “Hot Zone”, “Warm Zone”, and the “Cold
Zone”. An individual who is considered
contaminated, but is a Code Red would be taken to
which area first?
A code red patient is taken immediately to the hospital.
The EMT’s perform chemical decontamination on this
individual en route to the hospital.
B. All patients are taken to the “Hot Zone” first for
minimal triage and medical care. Triage is done in this
area to determine expectant status.
C. This patient would proceed directly to the Cold Zone for
treatment and would skip the decontamination process.
D. A code red patient would not be removed from the
contaminated area as his chances of survival are poor.
A.
34. Triage in the field for chemical incidents are divided
into the “Hot Zone”, “Warm Zone”, and the “Cold
Zone”. An individual who is considered
contaminated, but is a Code Red would be taken to
which area first?
A.
A code red patient is taken immediately to the hospital.
The EMT’s perform chemical decontamination on this
individual en route to the hospital.
B. All patients are taken to the “Hot
Zone” first for minimal triage and
medical care. Triage is done in this
area to determine expectant status.
This patient would proceed directly to the Cold Zone for
treatment and would skip the decontamination process.
D. A code red patient would not be removed from the
contaminated area as his chances of survival are poor.
C.
In the Field:
Hot Zone: area immediately
adjacent to the location of
the incident. Minimal
triage/medical care –
limited to airway and
hemorrhage control,
administration of antidotes,
and identification of
expectant cases.
In the Field….
Warm Zone: a distance of at least 300 feet
from the outer perimeter of the hot zone.
Upwind, uphill from the contaminated
area. Rapid triage to determine expectant
status. Minimal treatment. Priority is to
decontaminate.
In the Field….
Cold Zone: Area adjacent (uphill and
upwind) from warm zone.
Decontaminated victims seen. Thorough
triage. Victims directed for treatment.
35. Staff in the field must wear
protective gear in which of the
following areas:
A. Hot Zone only.
B. Warm Zone only.
C. Hot and warm zones, required in cold
zone if unable to secure a location for
this zone which is uphill and upwind.
D. Hot, Warm, and Cold Zone.
35. Staff in the field must wear
protective gear in which of the
following areas:
A. Hot Zone only.
B. Warm Zone only.
C. Hot and warm zones, required in cold
zone if unable to secure a location for
this zone which is uphill and upwind.
D. Hot, Warm, and Cold Zone.
36. Which of the following patients could
enter the area designated as the “cold
zone”?
A.
A Code Yellow patient who not gone through
the decontamination process.
B.
A Code Green patient who is ambulatory and
has not gone through the decontamination
process.
C.
A Code Red patient who is deemed too critical
to go through the decontamination process.
D. A Code Red patient who has gone through
litter decontamination in the Warm Zone.
36. Which of the following patients could
enter the area designated as the “cold
zone”?
A.
B.
C.
A Code Yellow patient who not gone through the
decontamination process.
…all must go through decontamination…
A Code Green patient who is ambulatory and has not
gone through the decontamination process.
all must go through decontamination…
A Code Red patient who is deemed too critical to go
through the decontamination process.
D. A Code Red patient who has gone
through litter decontamination in
the Warm Zone.
37. A train near the city’s high school has derailed and
has spilled radioactive material onto the roadways.
The school nurse should communicate which of the
following statements to the parents of the
students?
A. The buses will not run this afternoon. Parents
must arrange for alternate transportation home
for their children.
B. Parents are required to give verbal permission
(over the phone) for their child to drive their
vehicle home under these conditions.
C. The students will be kept at the High School
until the local authorities declare the area as
being “all clear”.
D. The students will be allowed to walk home as
long as they avoid the contaminated area.
37. A train near the city’s high school has derailed and
has spilled radioactive material onto the roadways.
The school nurse should communicate which of the
following statements to the parents of the
students?
The buses will not run this afternoon. Parents must
arrange for alternate transportation home for their
children.
B. Parents are required to give verbal permission (over the
phone) for their child to drive their vehicle home under
these conditions.
A.
C. The students will be kept at the
High School until the local
authorities declare the area as being
“all clear”.
D. The students will be allowed to walk home as long as
they avoid the contaminated area.
38. A triage nurse working in the Warm Zone at a
hospital’s emergency room receives a patient
transported by ambulance from the site of a
chemical spill. What action should she take first?
A. Admit the patient to the main section of
the hospital’s emergency room.
B. Determine the decontamination that
occurred in the field.
C. Assess the patient.
D. Administer oxygen via nasal cannula.
38. A triage nurse working in the Warm Zone at a
hospital’s emergency room receives a patient
transported by ambulance from the site of a
chemical spill. What action should she take first?
A. Admit the patient to the main section of
the hospital’s emergency room.
B. Determine the
decontamination that
occurred in the field.
C. Assess the patient.
D. Administer oxygen via nasal cannula.
39. An 80-year old client recovering from a
CVA is being transferred to a skilled
nursing facility. The nurse should assign
this client to which of the following staff
members?
A UAP who is about to graduate from a
baccalaureate nursing program.
B. A certified nursing assistant with 10 years
experience.
C. A new graduate who passed the NCLEX last
week.
D. An LPN with 25 years experience at this facility.
A.
39. An 80-year old client recovering from a
CVA is being transferred to a skilled
nursing facility. The nurse should assign
this client to which of the following staff
members?
A UAP who is about to graduate from a
baccalaureate nursing program.
B. A certified nursing assistant with 10 years
experience.
A.
C. A new graduate who passed the
NCLEX last week.
D. An LPN with 25 years experience at this facility.
40. A patient tells you that he suspects that
a nursing assistant has stolen his
watch. What action should you take?
Report the accusation to the hospital’s public
relations department.
B. Watch the nursing assistant to see if she’s
wearing the watch.
C. Listen outside the break room door to the
nursing assistant’s conversation with her
friends to see if she incriminates herself.
D. Report the accusation to your immediate
supervisor.
A.
40. A patient tells you that he suspects that
a nursing assistant has stolen his
watch. What action should you take?
Report the accusation to the hospital’s public
relations department.
B. Watch the nursing assistant to see if she’s
wearing the watch.
C. Listen outside the break room door to the
nursing assistant’s conversation with her
friends to see if she incriminates herself.
A.
D. Report the accusation to your
immediate supervisor.
41. A man is prepared for discharge during the
7-3 shift. He was admitted for treatment of
AIDS and Candida esophagitis. Who should
be assigned to care for this patient?
The LPN who has worked on this unit for 10
years.
B. The nursing assistant who has just completed
an in-service on the special needs of AIDS
patients.
C. The RN who has 3 years experience on this
nursing unit.
D. The RN who was pulled to this unit from the
Cardiac ICU.
A.
41. A man is prepared for discharge during the
7-3 shift. He was admitted for treatment of
AIDS and Candida esophagitis. Who should
be assigned to care for this patient?
The LPN who has worked on this unit for 10
years.
B. The nursing assistant who has just completed
an in-service on the special needs of AIDS
patients.
A.
C. The RN who has 3 years
experience on this nursing unit.
D. The RN who was pulled to this unit from the
Cardiac ICU.
42. Which area described below would be
most ideal to serve as the “Cold Zone”
in the Field after a chemical incident?
A. The parking lot immediately beside the roadway
where a truck carrying a chemical toxin has
crashed.
B. The gym that is located 100 feet from the
location of the crash of a truck carrying a
chemical toxin, and is uphill and upwind of the
chemical incident.
C. The main building of an elementary school,
located over 300 feet from the outer perimeter
of the “Hot Zone”, and is uphill and upwind of
the chemical incident.
D. The hospital emergency room.
42. Which area described below would be
most ideal to serve as the “Cold Zone”
in the Field after a chemical incident?
A. The parking lot immediately beside the roadway where
a truck carrying a chemical toxin has crashed.
B. The gym that is located 100 feet from the location of
the crash of a truck carrying a chemical toxin, and is
uphill and upwind of the chemical incident.
C. The main building of an elementary
school, located over 300 feet from
the outer perimeter of the “Hot
Zone”, and is uphill and upwind of
the chemical incident.
D. The hospital emergency room.
In summary
Delegation:
•Teaching
•Assessment
•Specialized skills
Prioritization



Most acute basic need
Eliminate expected/usual
Pain is the answer ONLY if there is a
sudden increase or it is unusual pain
Triage


Red seen first…most acutely ill with best
chance of survival.
In disaster select the answer that will do
the most good for the most people as your
first course of action
African American




Head nodding does not always mean
agreement.
Time orientation varies according to age,
socioeconomic subgroup
Elderly respected, large extended family is
important
Religion source of strength
Asian American





Silence valued
Eye contact may be considered
inappropriate
Head nodding does not always mean
agreement
Usually will not touch others during
conversation
Head is considered sacred
European (white) origin American




Silence can be respectful or disrespectful
Time is valued
Man is dominant figure
Tendency to be stoical when expressing
physical concern
Hispanic American




Avoiding eye contact with authority person
indicates respect
Dramatic body language is used to
express emotions or pain
May place more value on relationship and
events than being on time
Extended family is highly regarded
Native America




Silence shows respect
Eye contact is viewed as disrespectful
Personal space is important
Elders are honored
43. The nurse is providing care to a Cuban American client
who is terminally ill. Numerous family members are present
most of the time, and many of the family member are
emotional. What is the most appropriate action?
1.
2.
3.
4.
Restrict the number of family members visiting
at one time.
Inform the family that emotional outburst are
to be avoided.
Request permission to move the client to a
private room and allow the family to visit.
Contact the physician to speak to the family
regarding their behaviors.
43. The nurse is providing care to a Cuban American client
who is terminally ill. Numerous family members are present
most of the time, and many of the family member are
emotional. What is the most appropriate action?
1.
2.
3.
4.
Restrict the number of family members visiting
at one time.
Inform the family that emotional outburst are
to be avoided.
Request permission to move the
client to a private room and allow
the family to visit.
Contact the physician to speak to the family
regarding their behaviors.
44. The nurse is planning to instruct the Mexican American
client about nutrition and dietary restrictions. What should
the nurse be aware of in developing a plan for this ethnic
group.
1.
2.
3.
4.
Enjoys food that lacks color, flavor, and
texture.
Primarily eats raw fish.
Enjoys eating red meat.
Views food as a primary form of
socialization.
44. The nurse is planning to instruct the Mexican American
client about nutrition and dietary restrictions. What should
the nurse be aware of in developing a plan for this ethnic
group.
1.
2.
3.
4.
Enjoys food that lacks color, flavor, and
texture.
Primarily eats raw fish.
Enjoys eating red meat.
Views food as a primary
form of socialization.
45. Which of the following interventions is unlikely to
facilitate effective communication between the dying client
and his or her family?
1.
2.
3.
4.
The nurse encourages the client and family to
identify and discuss feelings openly.
The nurse makes decisions for the client and
family to relieve them of unnecessary
demands.
The nurse assists the client and family in
carrying out spiritually meaningful practices.
The nurse maintains a calm attitude and one
of acceptance when the family or client
expresses anger.
45. Which of the following interventions is unlikely to
facilitate effective communication between the dying client
and his or her family?
1.
2.
3.
4.
The nurse encourages the client and family to
identify and discuss feelings openly.
The nurse makes decisions for
the client and family to relieve
them of unnecessary demands.
The nurse assists the client and family in
carrying out spiritually meaningful practices.
The nurse maintains a calm attitude and one
of acceptance when the family or client
expresses anger.
46. Which of the following allows a client to provide
instructions to the physician regarding end of life decisions?
1.
2.
3.
4.
Living Will
Durable Power of Attorney for Healthcare
Substituted Decision affidavit
Do Not Resuscitate Order
46. Which of the following allows a client to provide
instructions to the physician regarding end of life decisions?
1.
2.
3.
4.
Living Will
Durable Power of Attorney for Healthcare
Substituted Decision affidavit
Do Not Resuscitate Order
47. Which of the following statements about informed
consent represents a need for an intervention by the nurse.
Select all that apply
1.
2.
3.
4.
5.
“I agree to surgery but now what is
going to be done.”
“Whatever needs to be done just do it.”
“I consent to the surgery in spite of the
risks.”
“My wife insists I have this surgery.”
“This was a difficult decision but I had
the information to make the decision.”
47. Which of the following statements about informed
consent represents a need for an intervention by the nurse.
Select all that apply
1.
2.
3.
4.
5.
“I agree to surgery but now what is
going to be done.”
“Whatever needs to be done just do
it.”
“I consent to the surgery in spite of the risks.”
“My
wife insists I have this
surgery.”
“This was a difficult decision but I had the information
to make the decision.”
48. The client has agreed to participate in a double-blind
study. Which statement indicates that the client does not
understand the study risks?
1.
2.
3.
4.
“I can quit the study at any time.”
“ My personal health information will be
protected during the study.”
“The consent form identified the risks of the
study.”
“The researcher will tell be what medication I
am receiving.”
48. The client has agreed to participate in a double-blind
study. Which statement indicates that the client does not
understand the study risks?
1.
2.
3.
4.
“I can quit the study at any time.”
“ My personal health information will be
protected during the study.”
“The consent form identified the risks of the
study.”
“The researcher will tell be
what medication I am
receiving.”