RN VATI Leadership 2016 Assessment,100% CORRECT

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RN VATI Leadership 2016 Assessment Fidelity means keeping one's promises or commitments. Although the staff nurse has a duty to client care, it is not in the best interest to have the nurse who is il... l come to work. This places clients and other staff members at risk for developing influenza. The Patient Self-Determination Act requires acute care facilities to have documentation in the medical record that a client has advance directives. The nurse should document the client's wishes for other health care workers who are caring for the client to understand the client's plan of care. Functional nursing, also called task nursing, involves the nurse manager breaking down the needs of the clients into tasks and assigning the tasks using the skill and licensure of each staff member appropriately and efficiently. This model of nursing is uncommon in acute care settings, except in crisis situations, or when there is a shortage in staffing numbers. Modular nursing is a type of team nursing in which a manager assigns a team of staff of various skills and licensure to a given geographic area (or module), often called care pairs. An example of modular nursing is assigning a team to a group of clients' rooms. Team nursing is the most common nursing care delivery system. The nurse manager divides the nursing staff into teams, including staff of various skills and licensure. Each team provides total care to a specific group of clients and has a team leader. Primary nursing is a form of total client care in which one nurse has 24-hr responsibility and accountability for the nursing care of specific clients for the duration of their stay at the facility to promote clear communication among the health care team. The first action the nurse should take when using the nursing process is assessment. By determining the unit staff's perception of the need for change, the nurse manger will be able to implement effective change. Cracks in the sidewalk leading to the client's front door is correct. Cracks in the concrete can create an uneven walkway that increases the client's risk for tripping and falling. A throw rug over worn-out vinyl flooring in the client's bathroom is correct. Although flooring that has deteriorated can create a safety hazard, covering it with a throw rug can increase, rather than decrease, the client's risk for falls. A raised vinyl seat on the toilet in the client's bathroom is incorrect. A raised toilet seat makes it easier for the client to sit and get up without becoming unstable or losing balance. Thus, it decreases the client's fall risk. A mattress on the floor of the client's bedroom is incorrect. Clients who are at risk for falling out of bed can reduce the risk by sleeping on a mattress that is directly on the floor. An extension cord taped securely to flooring in the hallway is correct. Taping an extension cord to flooring in the hallway can create an uneven walking surface that increases the client's risk of tripping and falling. The tape can also become loose over time and further increase the risk for the client to fall. The client who has dry and irritated skin is at a greater risk for skin breakdown and the development of a pressure ulcer. The nurse should minimize dryness by applying moisturizing lotions while the client's skin is moist after bathing. The nurse should elevate the head of the client's bed to no more than 30° when the client is in a lateral position to reduce injury occurring from friction and shearing forces. Libel is a false written statement about a client's status that can result in injury. If the nurse documents that the client has a substance use disorder without any evidence to support that allegation, that written statement is libelous. Gross negligence is an extreme breach of care with an intentional, reckless disregard of consequences. The nurse's actions were intentional and reckless, in opposition to the provider's prescription, and placed the client at risk for pain and injury. False imprisonment is the unlawful, intentional confinement of a person within fixed boundaries. Although it can be difficult for a client who is in intense pain to rise from sitting or summon help, the nurse did not unlawfully confine the client to the chair or the room. Battery refers to harmful or offensive touching without consent. There is no indication that the nurse touched the client in an inappropriate or harmful manner. Document completed nursing interventions at the end of the day is incorrect. The nurse should document nursing interventions as soon as the tasks are completed. Waiting until the end of the day to document nursing interventions increases the risk for inaccuracy and error. Complete small tasks first that require the least amount of time and energy is incorrect. The nurse should complete large tasks that require the most time and energy at the beginning of the shift when energy levels are high. Organize tasks around the priority needs of the clients is correct. The nurse should organize tasks around the priority needs of the clients to decrease the risk of needs not being met in a timely manner. Create a list of all planned activities is correct. The nurse should create a list of all planned activities to ensure that time management and goals are being met. Delegate tasks to assistive personnel is correct. The nurse should delegate appropriate tasks to assistive personnel to ensure that time management and goals are being met. The nurse should identify that the client's abdominal distention requires gastric decompression by inserting a nasogastric tube along with low intermittent suction to relieve the pressure in the client's abdomen and remove blood or fluid that might be in the gastrointestinal tract. This will also provide comfort to the client. The nurse should observe nonverbal expressions while the client is communicating with the interpreter. Body language and nonverbal expressions can assist the nurse to determine the client's understanding of the information. The nurse manager should use a formalized system to discuss important issues and selectively determine the areas of most importance that have the greatest effect on client care during the performance appraisal. The nurse manager should focus on the nurse's performance throughout the appraisal period by collecting data systematically and on a regular basis, because recent performance is often more heavily evaluated than past performance. The nurse manager should set goals together with the nurse during the performance appraisal. This information provides recent assessment data indicating the client's current condition and is part of the assessment portion (A) of the SBAR communication tool. The provider should periodically evaluate and revise the DNR order as the client's condition changes. Delivering diet trays to the wrong clients requires correction of the error before the clients eat; however, this does not place clients at risk and does not require completion of an incident report. This situation is identified as a near miss because the client was not injured and no property was damaged. Returning the client to the wrong room after surgery needs to be resolved; however, this does not place the client at risk and does not require completion of an incident report. This situation is identified as a near miss because the client was not injured and no property was damaged. Discovering an incorrect insulin dosage recorded on the medication administration record requires a correction to be made; however, this does not place the client at risk and does not require completion of an incident report. This situation is identified as a near miss because the client was not injured and no property was damaged. Losing a client's dentures requires an incident report to be completed. In this situation, the client's personal property was lost and requires the creation of an incident report to track the progress of the occurrence. A client who has a traumatic amputation requires immediate intervention for survival; therefore, when using the survival approach to client care, the nurse should give priority for transfer to this client. A client who has severe head trauma has a minimal chance of survival even with intervention; therefore, the nurse should not recommend this client for first transport A nurse refuses to administer dialysis to a client who has a terminal diagnosis is incorrect. The nurse should recognize that advocacy involves following the Nurses' Code of Ethics, which dictates that nurses are required to care for all persons, regardless of the nature of their health problem. The nurse should contact the provider if the client is refusing to receive dialysis, which is an example of advocacy. A nurse reports a procedure was completed incorrectly by another nurse to the charge nurse is correct. The nurse should report improper completion of a procedure to the charge nurse and complete an incident report describing the incident. Reporting to the charge nurse is an act of advocacy for the client, which allows the charge nurse to further monitor the client's condition and prevent negative outcomes. A nurse refuses to use a multi-dose vial of medication for the same client is incorrect. The nurse does not demonstrate client advocacy when refusing to use a multi-dose vial for a single client, because this action does not promote cost effectiveness of client care. A nurse arranges for an interpreter for a client is correct. The nurse should arrange for an interpreter, which is an example of client advocacy, to facilitate understanding of the teaching and allow the client to relay his needs to the nurse. A nurse administers medication in applesauce after a client refuses the medication is incorrect. The nurse should recognize that advocacy involves recognition of the rights of the client to refuse treatment, including medications. By administering a medication to the client who refused it, the nurse is failing to follow the Nurses' Code of Ethics and is not acting as a client advocate. The first action the nurse manager should take using the nursing process is to assess acuity, staffing, and scheduling needs. Nurse managers have a responsibility to ensure that the staff delivers cost-effective, high- quality care. Collecting data that support decision-making can help managers monitor and correlate staffing, client acuity levels, and scheduling patterns in relation to budget requirements. The role of the nurse as a client advocate involves directly intervening on behalf of the client. An example of this is contacting the provider for the client to find an alternative pain management plan. The ethical principle of nonmaleficence emphasizes that one should do no harm to clients. By clarifying the prescription with the provider, the nurse is ensuring that no harm can occur from administering an incorrect medication dosage to the client. Observing the AP is an effective way for the nurse manger to evaluate the AP's use of the equipment. This method of assessment also assists in determining the need for further education and staff development. The nurse manager should include the staff in the process by formulating a sample staffing schedule covering 1 month, allow the staff to view the schedule, and provide feedback. Resistance to change is an integral part of the process of change. A common reaction to any change, when it relates to scheduling, is a fear of loss of hours and lack of trust from the employee to the employer. The nurse should inform the provider that the grandfather is the closest adult relative available for signing the informed consent in this emergency situation when parents are not available. The nurse should negotiate with the nursing supervisor about specific tasks to perform, to ensure the nurse is providing safe care at the nurse’s level of training and competence. when floating to a different unit The first step the nurse should take when preparing to administer packed RBCs is to initiate an IV site with an 18- to 20-gauge IV catheter. Next, the nurse should infuse a solution of 0.9% sodium chloride to maintain IV catheter patency. Then the nurse should obtain the unit of packed RBCs for transfusion from the blood bank. Once the blood is obtained, the nurse should verify the information on the blood bag with the client's medical record and arm bracelet with another nurse. Finally the nurse should insert the Y spike of the tubing used for blood product infusion into the blood bag. The nurse should always document assessment findings in the client's medical record and notify the provider of the suspected abuse. Reporting requirements vary from state to state, so the nurse must be aware of and follow local guidelines for reporting suspicions of abuse. The nurse should plan to release the restraint at least every 2 hr. This allows the nurse the opportunity to assess the client's needs for nutrition and toileting as well as assess the skin and provide range-of-motion exercises. The nurse should check the constriction of the restraint by inserting two fingers under the restraint. A restraint that is too tight can interfere with circulation, which can result in neurovascular injury. The nurse should plan to release the restraint at least every 2 hr. This allows the nurse the opportunity to assess the client's needs for nutrition and toileting as well as assess the skin and provide range-of-motion exercises. The nurse manager should collect reports from other employees, client concerns, and observations, as well as statements detailing any related incidents that support the nurse manager's suspicion that substance use may be involved. The nurse manager can then refer the nurse to an employee assistance program. (The nurse manager should discuss the situation with the facility administrator when there is confirmation that the nurse has a substance use disorder.) Petroleum-based products can lead to combustion. The client should use only water-based products to moisturize dry nasal passages. Smoothing compliments the opponent, downplays differences, and focuses on minor issues of agreement as though no real disagreement existed. This technique is ineffective for major conflicts. Accommodation is a passive way of dealing with conflict by giving false reassurances instead of dealing with the issue. It can preserve harmony when one person has a vested interest in an issue that is unimportant to the other party. During collaboration, both parties agree to work together to find a mutually satisfying solution to the conflict. This strategy is useful when the goals of both parties are too important for compromising. Conflict management by competition involves one person dominating others. It places winning above all else, including the costs of winning. It might be necessary in situations that involve unpopular or critical decisions, or when time does not permit for more cooperative techniques. Outcome standards measure if the services the nurses provide make any difference in a client's health status. The outcome would be a change in clients' current or future health status as a result of the care they received. Other examples of outcome standards include clients ambulating without assistance or clients who have clear breath sounds Process standards focus on how well a facility conducts its activities. An example of a process standard is staff measuring vital signs every hour unless otherwise specified. Structure standards focus on the internal characteristics of a facility and its staff. The standards help determine if a facility has a structure that promotes high-quality care. An example of a structural standard is a nursing department providing opportunities for staff development to the nursing staff. The nurse is acting as a client advocate when the nurse contacts a social worker to assist the client with daily meal delivery services. Client advocacy involves contacting available resources on behalf of the client. The nurse should document the client's emotional concerns regarding discharge; however, this is not a demonstration of client advocacy. The nurse should identify the health care proxy can make health care decisions for the client if the client is no longer able to make decisions regarding treatment. The client should discuss his health care wishes with the health care proxy while he is able. The client's living will authorizes a designated health care proxy or the client's provider to use the living will for health care decisions when the client is no longer able to make decisions regarding treatment. The nurse should recommend a referral to a speech-language pathologist for a client who has had a stroke and exhibits dysarthria. Dysarthria is slurred speech resulting from paralysis of the tongue and muscles used for speaking. Early intervention by a speech-language pathologist can improve the client's recovery. Occupational therapist is correct. An occupational therapist helps the client who has physical limitations or disabilities gain an optimal level of independence to perform ADLs, such as bathing, dressing, grooming, and eating. Physical therapist is correct. A physical therapist can assess the client's strength and mobility, implement therapeutic strategies, and teach new skills to help compensate for physical limitations and help manage ADLs. Audiologist is incorrect. An audiologist specializes in assessing and determining hearing loss. There is no indication that the client needs a hearing assessment. Respiratory therapist is incorrect. A respiratory therapist can administer pulmonary function tests and assist in providing therapies, such as oxygen, to help manage respiratory health. There is no indication that the client needs respiratory support. Speech-language pathologist is correct. A speech-language pathologist can perform an in-depth assessment of the client's swallowing and communication abilities, and teach the client strategies for eating safely and performing other ADLs. Respite care services provide time away from caregiving responsibilities to attend to errands, needs, or social activities. A person who can care for the client temporarily at home makes it possible for the partner to step away from the client and know that the client will receive the necessary care. Assisted living facilities provide assistance to clients who remain somewhat independent and live within the facility. The nurse should not suggest this service because the client's partner plans to provide care at home. The nurse should recommend a client who is medically stable for early discharge from the acute care facility. A young adult client who has a new diagnosis of diabetes insipidus is in need of acute medical care. The nurse should recommend a client who is medically stable for early discharge from the acute care facility. The nurse should select the older adult client who had a total knee arthroplasty 1 week ago for discharge to a rehabilitation facility or home to receive home health services. The nurse should recommend a client who is medically stable for early discharge from the acute care facility. The nurse should select the older adult client who had a total knee arthroplasty 1 week ago for discharge to a rehabilitation facility or home to receive home health services. The nurse should recommend a client who is medically stable for early discharge from the acute care facility. An adult client who had a bowel resection 1 day ago is in need of acute medical care. Tell the nurses to lower their voices when discussing a client is incorrect. This action implies that it is acceptable to discuss a client's protected health information as long as no one can overhear the discussion. Plan an in-service program for the nurses about HIPAA privacy rules is correct. A presentation about confidentiality is a good reminder for nurses. It will reinforce to the nurses the importance of protecting client confidentiality. Ask the nurses to stop discussing the client's protected health information is correct. The nurse should take immediate action to inform the nurses that they have breached the client's confidentiality and to stop sharing any more information about the client. Inform the nurse manager about the confidentiality breach is correct. It is possible that the nurses misunderstood their responsibility to adhere to HIPAA privacy rules. The nurse manager is the appropriate person to re-teach these basic legal concepts and can assist in providing an inservice. Complete an incident report about the nurses' breach of confidentiality is incorrect. An incident report should be completed for an unusual or unexpected event such as a client fall, medication error, or occurrence that results in physical harm to the client. A breach of confidentiality does not require completion of an incident report. When cleaning a surgical instrument that is contaminated following a client procedure, the nurse should first rinse the instrument under cold water to remove organic materials. Next, the nurse should wash the instrument with soap and water to remove any remaining organic materials. Next, the nurse should use a brush to clean organic materials from any grooves in the instrument. Then, the nurse should use warm water to rinse the instrument. Finally, the nurse should dry the instrument before sterilization occurs. [Show More]

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