A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which of the following activities would be the lowest priority for the nurse?

Maintaining a client tracking system

Performing concise client assessment

Preventing cross-contamination of clients

Transferring a client to the discharge location

Answer and Explanation

The Correct Answer is D

Rationale:

A. Maintaining a client tracking system is crucial for managing large numbers of clients during a disaster.

B. Performing concise client assessment is essential for determining the severity of each client’s condition and prioritizing care.

C. Preventing cross-contamination of clients is important to prevent the spread of toxic substances.

D. Transferring a client to the discharge location is the lowest priority during a disaster, as immediate care and management of acute conditions take precedence over discharge planning.

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Correct Answer is B

Explanation

Rationale:

A. The nurse does not relinquish accountability when delegating tasks to an AP; the nurse remains responsible for the overall care and outcomes.

B. Considering the AP's level of experience is crucial for effective delegation to ensure that tasks are matched to the AP's skills and knowledge.

C. Providing client education is generally beyond the scope of AP duties and should be performed by a licensed nurse.

D. Re-delegating tasks is not allowed; the original delegator remains responsible for ensuring the task is completed properly and should delegate directly to the appropriate individual.

A. "The client works in the hospital radiology department." B. "The client discussed having prior thoughts of suicide." C. "The client's blood pressure and pulse have been fluctuating throughout the day." D. "The client's family members have been present most of the day."

Correct Answer is C

Explanation

A. "The client works in the hospital radiology department": This information is irrelevant to the client’s current health status and does not imply a need for total care by the nurse.

B. "The client discussed having prior thoughts of suicide": While suicidal ideation is serious and requires careful monitoring and assessment, this information alone does not necessarily indicate that the nurse must assume total care. A nurse would still delegate non-critical tasks to the AP, but constant monitoring and appropriate interventions would still be the nurse’s responsibility.

C. "The client's blood pressure and pulse have been fluctuating throughout the day": Fluctuating vital signs, especially blood pressure and pulse, can indicate an unstable condition that may require immediate attention and careful monitoring. This scenario suggests that the client’s condition may be critical and requires ongoing assessment and evaluation by the nurse, rather than simply delegating tasks like monitoring vital signs to assistive personnel (AP). The nurse needs to assess the situation thoroughly, interpret the fluctuations, and adjust the care plan accordingly.

D. "The client's family members have been present most of the day": Family presence alone does not impact the need for total care by the nurse. It is important for the nurse to communicate with the family, but this statement does not indicate the need for the nurse to assume total care over other team members.

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A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which of the following activities would be the lowest priority for the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is providing an inservice program about delegation to assistive personnel (AP) with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?

Correct Answer is C

Explanation

A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation?

An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for?

A charge nurse is discussing disaster response with nursing staff. Which of the following statements indicates an understanding of the Hospital Incident Command System (HICS)?

A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?

A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?

A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes an incident report, which of the following actions should the nurse take?

A nurse manager has received information from the facility's risk management department that a former client is pursuing a lawsuit. The nurse manager should anticipate a deposition will be required during which phase of the legal process?

A nurse is obtaining informed consent from a client who is preoperative. Which of the following actions should the nurse take? (Select all that apply.)