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1. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP) working in the diabetic clinic?
- A. Measure the ankle-brachial index.
- B. Check for changes in skin pigmentation.
- C. Assess for unilateral or bilateral foot drop.
- D. Ask the patient about symptoms of depression.
Correct answer: A
Rationale: The correct answer is A: Measure the ankle-brachial index. This task involves using a Doppler ultrasound device to assess blood flow, which can be safely delegated to UAP. Choices B, C, and D require a higher level of assessment and interpretation that should be performed by licensed nursing staff. Checking for changes in skin pigmentation (B) and assessing for foot drop (C) involve more complex assessments that require nursing judgment. Asking about symptoms of depression (D) involves a psychosocial assessment, which should be performed by licensed personnel qualified to address mental health concerns.
2. Which of the following is a recommendation for avoiding charges of negligence and false imprisonment for confused clients?
- A. Carefully assess and document client status.
- B. Ensure all patient information is secure and the nurse has logged out of the computer before leaving the computer station.
- C. Keep detailed notes while providing care to ensure accurate documentation later in the day.
- D. Discuss safety needs with clients.
Correct answer: A
Rationale: The correct answer is A: 'Carefully assess and document client status.' When dealing with confused clients, it is crucial to assess their status carefully and document it accurately. This helps in avoiding charges of negligence and false imprisonment by ensuring that the client's condition is well-documented and appropriate care is provided. Choice B is incorrect because it focuses on computer security rather than client care. Choice C is incorrect because it emphasizes detailed notes for accuracy but does not specifically address the confusion of clients. Choice D is incorrect as it mentions discussing safety needs but does not directly relate to avoiding charges of negligence and false imprisonment for confused clients.
3. One of the steps in coaching is often overlooked and taken for granted. What is this step?
- A. Stating the target
- B. Jumping to conclusions
- C. Asking for suggestions
- D. Tying the problem to clients' care
Correct answer: D
Rationale: In coaching, tying the problem to clients' care is crucial but often overlooked. This step ensures that the coach and the client focus on issues directly impacting the client's well-being. Stating the target (choice A) is important but not as critical as tying the problem to clients' care. Jumping to conclusions (choice B) is counterproductive in coaching as it may lead to incorrect assumptions. Asking for suggestions (choice C) is valuable, but it does not address the core aspect of linking the issue to the client's care, which is essential for effective coaching.
4. A nurse manager is considering the variances of the budget. Fewer monies were spent than expected. What type of variance is this?
- A. Unfavorable variance
- B. Favorable variance
- C. Dependent variance
- D. Independent variance
Correct answer: B
Rationale: The correct answer is B, favorable variance. When fewer funds are spent than expected, it indicates efficient budget management, making it a favorable outcome. Choice A, unfavorable variance, is incorrect as it would apply if more money than expected was spent. Choices C and D, dependent variance and independent variance, are unrelated terms in the context of budget variances and do not apply to the situation described.
5. When a nurse observes a fellow nurse preparing an incorrect dose of medication, what is the best action to take?
- A. Ignore the error
- B. Administer the medication anyway
- C. Correct the error without informing the nurse
- D. Report the error to the supervisor immediately
Correct answer: D
Rationale: The best action to take when a nurse observes a fellow nurse preparing an incorrect dose of medication is to report the error to the supervisor immediately. Reporting the error is crucial to ensure patient safety and prevent any potential harm. Ignoring the error (Choice A) is not appropriate as it puts the patient at risk. Administering the medication anyway (Choice B) could harm the patient. Correcting the error without informing the nurse (Choice C) does not address the root cause of the issue, which should be brought to the attention of the supervisor for proper investigation and resolution.
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