Exam 4

Question 1

Definition of delegation

Answer 1

Transferring responsibility for the performance of an activity or task while retaining accountability for the outcome (ANA)

Question 2

Advantages of delegation

Answer 2

Improved efficiency, productivity, job enrichment

Question 3

What are the five rights of delegation?

Answer 3

Right task, right circumstances, right person, right direction/communication, right supervision

Question 4

What is direct delegation

Answer 4

Verbal direction for an activity/task- directed to a specific person

Question 5

Indirect delegation

Answer 5

Approved list of activities/tasks- general

Question 6

Right task

Answer 6

Within scope

Question 7

Right circumstances

Answer 7

Is this situation being handled appropriately? I.e. X2 assist is not going to be one person assisting the X2 pt by themselves

Question 8

Right person

Answer 8

Is this the person with the best skill set for this task?

Question 9

Right direction/ communication

Answer 9

Closed-loop communication= feedback (i.e. repeat back task to delegator) ex: code team

Question 10

Right supervision example

Answer 10

First day on the job? Trainer must be there with them.

Question 11

Ancillary personnel

Answer 11

Clericals

Question 12

What is a good rule of thumb to remember if you are not sure about whether a task can be delegated or not?

Answer 12

If you are not licensed to give it, you are not licensed to verify it- you cannot delegate it to them

Question 13

Can ancillary staff perform pt care?

Answer 13

No

Question 14

Unlicensed assistive personnel- UAP examples

Answer 14

CNA, NA, NI, PCP
ADL’s, baths, feeding, repositioning, no meds, no stitches and staples removal, central line insertion or maintenance

Question 15

Ancillary personnel are not to

Answer 15

Lay hands on pt, but can bring things like water, direct call lights to proper personnel

Question 16

What is the delegation decision making grid?

Answer 16

Level of pt acuity
Level of UAP’s ability
Level of licensed nurse capability
Potential for harm
Frequency of performance of skill
Level of decision making
Ability for self care

Question 17

considerations for delegation

Answer 17

Safest person for skill
Scope of practice
Training for task
Experience

Question 18

If a nurse delegates to another personnel, who is responsible for outcomes ?

Answer 18

The nurse who delegated- you maintain responsibility even if you did not physically do it yourself

Question 19

What are the pain scales we talked about in class?

Answer 19

FLACC, Wong-baker, numeric scale

Question 20

Who do we use the FLACC scale for?

Answer 20

Unconscious/nonverbal

Question 21

Wong-baker scale is

Answer 21

Faces

Question 22

Example of pain intensity

Answer 22

Mild, severe, moderate, excruciating

Question 23

Pain quality

Answer 23

Sharp, stabbing, aching, dull ,deep

Question 24

Things to know about pain

Answer 24

Location, anything makes it better, worst, quality, intensity

Question 25

Pain is

Answer 25

Subjective

Question 26

The patient is the

Answer 26

Determinant of pain

Question 27

T/F: chronic pain is purely psychological

Answer 27

False

Question 28

ABCDE of pain

Answer 28

Ask Believe Choose Deliver Empower

Question 29

A of ABCDE of pain

Answer 29

Ask about pain regularly, assess systematically

Question 30

B of ABCDE of pain

Answer 30

Believe the client and family about reports of pain and what relieves it

Question 31

C of ABCDE of pain

Answer 31

Choose pain control options appropriate for the client ,family and setting

Question 32

D of ABCDE of pain

Answer 32

Deliver interventions in a timely, logical

Question 33

Narcan/naloxone is a reversal for

Answer 33

Opioids

Question 34

Dantrolene

Answer 34

Tx for malignant hyperthermia

Question 35

Romazicon or ________

Answer 35

Flumazenil

Question 36

Flumazenil is a

Answer 36

Reversal agent for benzodiazepines

Question 37

Types of anesthesia

Answer 37

Local, general, conscious

Question 38

Local anesthesia

Answer 38

Used to numb or as a regional anesthetic. Ex= stitches

Question 39

Role of circulating nurse

Answer 39

Maintaining safety of the client; sterile field, monitors, items, counts Supplies before and after

Question 40

Assess for paralytic ileus

Answer 40

Listen for 5 min each quadrant; ask if they have passed gas or had a BM

Question 41

General anesthesia

Answer 41

Used for invasive surgeries, ex= open heart surgery

Question 42

Conscious anesthesia

Answer 42

Procedures like endoscopies, client subconsciously maintains their own airway

Question 43

How do you prevent a DVT post-op?

Answer 43

TEDS, SCDs, lovenox (blood thinner

Question 44

How to prevent post-op pneumonia

Answer 44

Coughing and deep breathing exercises, incentive spirometer, early ambulation

Question 45

What are the conditions to be eligible to give consent?

Answer 45

Must be 18 or older, in their right mind, not under any influence

Question 46

How would an individual not be able to give consent for a procedure or tx?

Answer 46

If they are under 18, under any type of influence, or physically unable to (i.e coma)

Question 47

How does having a disability affect giving consent?

Answer 47

It does not change their rights to consent if they are still in their right mind to do so. WE would accommodate to THEM (i.e. deaf, blind)

Question 48

What are the classifications of surgery?

Answer 48

Urgent, elective, emergent Minor/major

Question 49

Monitoring during conscious sedation

Answer 49

Maintain an airway on their own, start an airway if needed

Question 50

Dementia

Answer 50

Progressive, long-term condition

Question 51

Delirium

Answer 51

Short-term, after surgery; effects from coming out of anesthesia

Question 52

What is the difference between delirium and dementia?

Answer 52

The speed of onset

Question 53

What is the normal range for BP?

Answer 53

120/80

Question 54

What is considered a hypertensive crisis?

Answer 54

Anything over 180/100

Question 55

HTN medication education

Answer 55

Take it at the same time everyday, do not skip doses, avoid alcohol, do not abruptly stop the pill, know what type of diuretic you are on (potassium sparing vs wasting)

Question 56

Education for HTN pts on a potassium sparing diuretic

Answer 56

Avoid salt substitutes and foods containing potassium Bananas and white potatoes

Question 57

Education for HTN pts on a potassium wasting diuretics

Answer 57

Potassium supplements, eat potassium rich foods

Question 58

Reversible risk factors, another name is______

Answer 58

Modifiable risk factors

Question 59

Modifiable risk factors example

Answer 59

Diet, activity, lifestyle, smoking, alcohol

Question 60

Irreversible risk factors, another name is ________

Answer 60

Non-modifiable risk factors

Question 61

Non-modifiable risk factor examples

Answer 61

Age, gender, family history, ethnicity

Question 62

What is sensory overload

Answer 62

two or more stimulants occur simultaneously, overwhelming the client

Question 63

What is sensory deprivation

Answer 63

stimulants for the senses (sight, hearing, touch, etc,) are not present- pt begins to lose sensory function

Question 64

Sensory overload causes examples

Answer 64

lights,people, monitors, conversatoins, machines, TV, pictures, bedding

Question 65

Sensory deprivation causes examples

Answer 65

no pictures, magazines, color, human interaction, noise, light

Question 66

Nursing interventions for sensory overload

Answer 66

quiet environment(cluster care, limit visitors), low lighting, close door, tv off

Question 67

Nursing interventions for sensory deprivation

Answer 67

provide entertainment (TV, coloring, crosswords), allow visitors, pictures on walls, door open, check on pt and talk with them

Question 68

What are some care and safety measures that can be implemented for someone with sensory limitations or impariments?

Answer 68

Do not change the organization of the room , ensure the room is clutter free, arrange food in a clock arrangement on plate, ensure good lighting, accommodate to limitations