Detailed Answer Key

Houston Leadership 0316

1. A charge nurse allows two nurses who are arguing about who gets to go to lunch first, go together. The charge
nurse agrees to cover both nurse’s client care. The charge nurse displayed which of the following types of conflict
management?

A. Avoiding

Rationale: The charge nurse did not display avoiding, which is not to acknowledge or try to resolve the
conflict.

B. Competing

Rationale: The charge nurse did not display competing, which is when the charge nurse would make quick
or unpopular decision at the expense of another.

C. Compromising

Rationale: The charge nurse did not display compromising, which is when all parties involved are willing to
give up something in the resolution of the conflict.

D. Cooperating

Rationale: The charge nurse did display cooperating, which is resolution of the conflict by sacrificing and
allowing the staff nurses to get want.

2. A nurse in the cardiac catheterization lab implements a new procedure for achieving hemostasis of the cardiac
catheter insertion site. Which of the following is a distinguishing characteristic of a new standard of care?

A. Achievable

Rationale: Achievable is a measurement tool for setting standards, not a characteristic.

B. Measureable

Rationale: Measurable is a measurement tool for setting standards, not a characteristic.

C. Predetermined

Rationale: Predetermined is used to distinguish the characteristic for implementing a new standard of care.

D. Objective

Rationale: Objective is a measurement tool for setting standards, not a characteristic.

3. A nurse manager received a client request not to have a particular nurse care for her while at the acute care facility.
Which of the following is the most appropriate action by the nurse?

A. Document the issue on an incident report.

Rationale: The nurse manager documenting the issue on an incident report does not resolve the issue.

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B. Address the concern with the charge nurse.

Rationale: The nurse manager addressing the concern with the charge nurse will help to resolve the issue
by adjusting the assignments and then discussing the issue with the nurse that cared for the
client.

C. Explain to the client the nurse was having a bad day.

Rationale: The nurse manager explaining to the client the nurses work load does not resolve the issue.

D. Notify the human resources department.

Rationale: The nurse manager notifying the human resources department does not resolve the problem.

4. A charge nurse is preparing to introduce a new type of infusion pump to the unit nursing staff. Which of the following
statements by the charge nurse displays her as a change agent?

A. “I want to let everyone know today we start using a new infusion pump.”

Rationale: A change agent is an excellent communicator when change is impending, this statement is not
characteristic of a change agent.

B. “It is never too late to learn how to use a new infusion pump.”

Rationale: A change agent is knowledgeable of available resources to meet the needs of change for the
staff nurses, this statement is not characteristic of a change agent.

C. “I think sometime this week we will have an in-service on the new infusion pump.”

Rationale: A change agent plans ahead for education when a major change occurs, this statement is not
characteristic of a change agent.

D. “I want to remind everyone about the in-service on using the new infusion pump.”

Rationale: A change agent organizes and prepare available resources when change is going to occur and
informs the staff nurse of the change and education needed, this statement is characteristic of a
change agent.

5. Which of the following examples display interpersonal conflict?

A. Nurses on the day and night shift are conflicting regarding who should do client daily weights.

Rationale: The nurses conflicting among themselves to make a client care decision is an example of
intrapersonal conflict.

B. Nurses throughout the hospital disagree on having 8-hour shifts or 12-hour shifts.

Rationale: The nurses throughout an organization conflicting about length of shifts is an example of
intergroup conflict.

C. Nurse Jones is deciding between going to a professional meeting or attending a play.

Rationale:

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The individual nurse is struggling to make a personal or professional decision, which is an

example of intrapersonal conflict.

D. Nurse Lee is professionally threatened by Nurse Doe.

Rationale: The nurse who is threatened by another nurse may be experiencing bullying, this is an example
of interpersonal conflict. Interpersonal conflict arises from differing goals and value system.

6. A nurse is teaching a newly licensed nurse methods to reduce costs of client care. Which of the following
statements indicates understanding of the teaching?

A. “I should discourage clients from taking as needed pain medications.”

Rationale: The nurse should administer as needed pain medications upon client request to ensure
management of a client’s pain.

B. “I should perform perineal care on a client with an indwelling urinary catheter once a day.”

Rationale: The nurse should perform perineal care on a client with an indwelling urinary catheter at least 3
times a day to decrease risk of infection.

C. “I should encourage clients to receive an annual flu immunization.”

Rationale: The nurse should encourage clients to receive an annual flu immunization to prevent the need
for treatment and hospitalization necessary with influenza.

D. “I should use non-sterile gauze to cover a client’s open wound.”

Rationale: The nurse should use a sterile dressing to cover a client’s open wound to decrease the risk for
infection.

7. A charge nurse hears a provider speaking to a staff nurse in anger concerning incorrect supplies that are available.
Which of the following actions by the charge nurse displays conflict resolution?

A. Use aggressive communication skills.

Rationale: The charge nurse in conflict resolution should use assertive not aggressive communication
skills.

B. Assist the provider in identifying alternative solutions.

Rationale: The charge nurse in conflict resolution should assist the staff nurse, not the provider, to identify
alternative solutions.

C. Address the situation as soon as possible.

Rationale: The charge nurse in conflict resolution should address the situation as soon as possible to avoid
escalation.

D. Foster closed communication.

Rationale:

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The charge nurse in conflict resolution should foster open communication, not closed
communication, with the parties involved.

8. A nurse has received morning report on the following four clients. Which client should the nurse see first?

A. A client who has a calcium level of 10 mg/dL and reports having a headache

Rationale: This client is stable and does not require immediate attention. The calcium level is within the
expected reference range of 9-10.5 mg/dL. Symptoms of hypercalcemia include increased heart
rate and blood pressure, increased risk for blood clots, muscle weakness, and decreased
deep-tendon reflexes. Signs of hypocalcemia include painful muscle spasms, and tingling and
numbness in the hands and feet. The client’s report of a headache is unrelated to the calcium
level and does not require immediate attention.

B. A client who has a blood glucose of 68 mg/dL and reports mild sweating

Rationale: The expected reference range for blood glucose is 70-110 mg/dL. This client is exhibiting an
early sign of hypoglycemia. If untreated, the client’s condition will deteriorate. The client will
require an immediate intervention. Early symptoms of hypoglycemia include sweating, irritability,
anxiety, tachycardia, and hunger. Late symptoms include weakness, fatigue, confusion, and
seizures. TIRED is an acronym for early signs: tachycardia, irritability, restlessness, extreme
hunger, and diaphoresis.

C. A client who has acute glomerulonephritis and reports reddish-brown urinary output

Rationale: Acute glomerulonephritis is an inflammation of the glomerular capillaries. The expected

symptoms include hematuria, decreased urine output, and proteinuria. Clients should consume
a diet low in sodium and restrict fluid intake. This client does not require any immediate
intervention because the findings are expected.

D. A client who has cellulitis of the left lower extremity and reports pain in the affected leg

Rationale: Cellulitis is a generalized infection in deep connective tissue with staphylococcus or

streptococcus. It is usually a localized inflammation that may enlarge rapidly if not treated.
Expected findings include redness, warmth, edema, tenderness, and pain. This client will require
pain management and antibiotics, but this client is not the priority.

9. A nurse is assigned four postoperative clients. Which of the following clients should the nurse address first?

A. A client whose capillary blood glucose at 0800 was 110 mg/dL and at 1200 is 98 mg/dL

Rationale: The expected reference range for fasting capillary blood glucose is 70-99 mg/dL. The expected
reference range for 1-hr postprandial capillary blood glucose is less than 140 mg/dL. The 0800
capillary blood glucose level is above the normal fasting level. Surgery is a stressor, and
stressors elevate blood glucose levels, so it is not unusual for the capillary blood glucose level to
be elevated. Because the 1200 capillary blood glucose level is at an expected level, this should
not be of greatest concern to the nurse.

B. A client whose wound drainage at 0800 was sanguineous and at 1200 is serosanguineous

Rationale: Sanguineous drainage is bright red and indicates active bleeding. Serosanguineous drainage is

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pink (light red), watery, and a mixture of serum and blood. The change is expected as time
passes and the wound heals. If the drainage had changed from serosanguineous to
sanguineous, the nurse should suspect active bleeding or possible hemorrhage and should
report this change to the RN or provider immediately.

C. A client whose pain level on a scale of 1-10 at 0800 was a 2 and at 1200 is a 6

Rationale: Pain measurement is a subjective finding; it is whatever the client states it is. Intensity for a
rating of 1-3 indicates mild pain, 4-6 indicates moderate pain, and 7-10 indicates severe pain.
The stem does not give any information regarding when or if the client was medicated for pain.
The nurse who evaluated the pain should treat in accordance to the client’s wishes and the
provider’s prescriptions. It is not unusual for postoperative clients to experience pain. Therefore,
this would not be of greatest concern to the nurse.

D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg

Rationale: Although the 0800 blood pressure is classified as prehypertensive (systolic 129-139 mm Hg or
diastolic 80-89 mm Hg), it is not unusual for postoperative clients to have moderately elevated
blood pressures related to the stress of surgery, pain, and IV fluid infusions. The 1200 blood
pressure is considered normal (systolic 90-120 mm Hg and diastolic 60-80 mm Hg). The
concern is the significant drop in the blood pressure, which could indicate internal bleeding. The
licensed practical nurse should report this change to the RN for further assessment prior to
notifying the provider.

10. A nurse is caring for a client who has dementia and receives delivery of a daily newspaper. The nurse observes a
staff member reading the paper before it is given to the client. Which of the following actions by the nurse is
appropriate?

A. Report the incident to the unit manager.?

Rationale: The newspaper is considered a client’s personal property. The staff member has violated the
client’s rights. This action should be reported.?

B. Purchase a new paper for the client.?

Rationale: The purchase of another newspaper does not address the unprofessional behavior of the staff
member.?

C. Take no action at this time.

Rationale: Immediate action is needed. The client’s rights have been violated, and the nurse should report
the incident to the unit manager.

D. Ask the family for permission to share with the staff.

Rationale: The newspaper is the client’s personal property. The nurse should not ask a client or a client’s
family to use personal property.

11. A nurse is planning to use an SBAR communication tool when calling a provider. Which of the following
statements by the nurse is appropriate for the “B” step in this tool?

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A. “Client should be seen by a neurologist.”

Rationale: This statement is the Recommendation for action in the SBAR tool.

B. “Client was found unconscious on the floor in her home.”

Rationale: This statement is the Background or context of the situation in the SBAR tool.

C. “No provider’s prescriptions are available.”

Rationale: This statement is the Situation as it relates to the client in the SBAR tool.

D. “Client disoriented; pupils slow to respond to light.”

Rationale: This statement is the Assessment as it relates to the identified problem in the SBAR tool.

12. A charge nurse is making assignments for nursing personnel who will be caring for clients during the oncoming
shift. Which of the following does the charge nurse consider?

A. The comfort level of the nurses in delegating tasks to assistive personnel (AP).

Rationale: Nurses delegating tasks to assistive personnel need to be aware of the AP’s job description.

B. Personal comfort level in making the assignments.

Rationale: The charge nurse role requires the nurse be adequately prepared and able to make
appropriate assignments.

C. Social relationships between nurses working the oncoming shift.

Rationale: The charge nurse should be aware of the right person doing the right task on the right person;
social relationships among the nurses are not a consideration when making assignments.

D. Information needed by nurses to perform the assigned tasks.

Rationale: Making assignments requires knowing the necessary skill and information needed to complete
tasks.

13. The charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the
following is an example of overdelegation?

A. Assigning two assistive personnel (AP) to ambulate all clients

Rationale: Assigning two APs to ambulate 10 clients follows the rights of delegation and expectations of
the APs. It is not an example of overdelegation.

B. Assigning a new graduate nurse to perform a wet-to-dry dressing change

Rationale: Assigning a new graduate to perform a wet-to-dry dressing change follows the rights of
delegation and expectation of the nurse. It is not an example of overdelegation.

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C. Assigning the most efficient AP to perform glucometer monitoring

Rationale: Asking the most efficient AP to perform glucometer testing based on her efficiency in
performing this task is an example of overdelegation,

D. Assigning the most competent RN to perform a central line dressing change

Rationale: Assigning the most competent RN to perform a central line dressing change follows the rights
of delegation and expectations of the nurse. It is not an example of overdelegation.

14. The RN on a medical-surgical unit is planning care for a group of clients at the beginning of the shift. Which of the
following tasks should the nurse assign to the licensed practical nurse (LPN)?

A. Developing the plan of care for a client with an amputation

Rationale: Development of the plan of care is not within the scope of practice of the LPN.

B. Evaluating the outcomes of a new postoperative client

Rationale: Evaluating the client’s progress is not within the scope of practice of the LPN.

C. Analyzing data to identify issues for a client with uncontrolled diabetes

Rationale: Establishing client goals based on an analysis of data is not within the scope of practice of the
LPN.

D. Performing crutch walking of a client following knee replacement surgery

Rationale: Performing crutch walking is within the scope of practice of the LPN.

15. A severe storm resulted in an RN working with one assistive personnel (AP) on a medical-surgical unit. After
talking with the hospital incident commander, which of the following actions by the nurse is appropriate?

A. Focus on providing care that prevents life-threatening emergencies

Rationale: The hospital implements the triage method in a disaster, which focuses on providing care to
clients with any immediate threats to life.

B. Reinforce discharge teaching to clients

Rationale: The triage method in a disaster focuses on early discharge of clients who are medically stable.
Reinforcing discharge teaching is not a focus in the triage method.

C. Instruct the AP to focus on clients’ ADLs

Rationale: The triage method in a disaster focuses on meeting basic human needs which would not
include having the AP assist clients with ADLs.

D. Stock additional unit supplies

Rationale: The hospital implements the triage method in a disaster, which calls for ancillary personnel to

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stock additional unit supplies for nursing personnel.

16. A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the
following tasks should the nurse assign to the assistive personnel (AP)?

A. Application of antibiotic ointment to the arm of a client who has dermatitis.

Rationale: A nurse cannot delegate a task which requires assessment or evaluation of the client’s
progress with the plan of care such as application of medication to an infected area.

B. Obtaining medical history information from a stable client who is being admitted.

Rationale: A nurse cannot delegate a task which requires assessment such as obtaining information about
a client’s medical history.

C. Monitoring vital signs of a client who had an appendectomy 12 hr ago.

Rationale: Delegating the monitoring of vital signs of a client several hours after surgery is an appropriate
activity for the AP since it does not involve assessment, specialized knowledge or judgment.

D. Removal of the nasogastric tube of a client who has been receiving enteral feedings.

Rationale: A nurse cannot delegate a task which requires assessment and specialized skill or training
such as removing a nasogastric tube.

17. An RN is planning to delegate tasks to a licensed practical nurse (LPN). Which of the following is important for the
nurse to understand when delegating tasks to the LPN?

A. The state Nurse Practice Act

Rationale: The state Nurse Practice Act identifies the skill or educational level needed by a nurse to
complete a task as well as indicating items that can and cannot be delegated from a legal
perspective.

B. The National Association for Practical Nurse Education and Services Standards

Rationale: This association promotes and defends the practice and education of practical nursing, but
does not define tasks that can be delegated in each state.

C. The National Council of State Boards of Nursing Decision Tree

Rationale: The decision tree focuses on a step-by-step analysis that nurses can use to decide whether a
task can be delegated to assistive personnel.

D. The Omnibus Budget Reconciliation Act of 1987

Rationale: This act established regulations for the education and certification of assistive personnel.

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18. A nurse is orienting a group of new graduate nurses and explains the purpose of delegation. Which of the following
is an appropriate statement by the nurse?

A. “Delegation provides appropriate resources for the client.”

Rationale: Delegation allows work to be done by others and does not determine if the appropriate
resources are being provided for clients.

B. “Delegation permits a designated individual to meet a goal on your behalf.”

Rationale: Delegation is defined as directing the performance of others to accomplish goals of the nurse
and the facility.

C. “Delegation promotes discharge teaching activities for clients.”

Rationale: Delegation allows work to be done by others but teaching activities may not be delegated by
nurses since this requires specialized knowledge.

D. “Delegation decreases health care costs.”

Rationale: Reducing the cost of health care may be a result of appropriate delegation but this is not the
purpose of delegation.

19. A nurse is planning to assign obtaining the vital signs of postoperative clients to an assistive personnel (AP). The
nurse should assign obtaining vital signs for which of the following clients?

A. A client who is 3 hr postoperative following a thyroidectomy

Rationale: The client’s physiologic status and stability of vital signs are considerations when assigning
vital signs to an AP; these are a consideration in a client immediately following a thyroidectomy.

B. A client who is 3 hr postoperative following an abdominal hysterectomy

Rationale: The client’s physiologic status and stability of vital signs are considerations when assigning
vital signs to an AP; these are a consideration in a client immediately following an abdominal
hysterectomy.

C. A client who is 3 days postoperative following gastric bypass surgery

Rationale: The client’s physiologic status and stability of vital signs are considerations when assigning
vital signs to an AP; this client is 3 days postoperative and his condition would have stabilized
by this time.

D. A client who is 3 days postoperative following a craniotomy

Rationale: The client’s multisystem involvement following a craniotomy is a consideration when assigning
vital signs to an AP.

20. A newly licensed nurse is planning to delegate tasks to an assistive personnel (AP). Which of the following tasks
should the nurse plan to perform?

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A. Administration of an enema

Rationale: Administration of an enema is a task that an AP has been taught and should be able to
complete.

B. Application of antiembolic stockings

Rationale: Application of antiembolic stockings is a task that an AP has been taught and should be able
to complete.

C. Assessing a client’s sacrum for edema

Rationale: Assessment requires specialized knowledge of the nurse and cannot be delegated to an AP.

D. Assisting a client to cough and deep breath

Rationale: Assisting a client to cough and deep breath is a task that an AP has been taught and should be
able to complete.

21. A nurse has received the change of shift report and is delegating tasks to the assistive personnel (AP). The nurse
should tell the AP to perform which of the following tasks first?

A. Perform blood glucose monitoring of a client who has a prescription for short acting insulin prior to breakfast

Rationale: Knowing the client is an important criterion when making a safe, effective delegation decision.
In this case, the timing of the client’s insulin and breakfast make this the priority task to be
delegated since these may result in a rapid change to the client’s condition.

B. Apply a condom catheter for a client who is incontinent.

Rationale: Knowing the client is an important criterion when making a safe, effective delegation decision.
Assigning this task to the AP is unrelated to a possible rapid change in the client’s condition.

C. Feed a client who has bilateral casts due to upper arm fractures.

Rationale: Knowing the client is an important criterion when making a safe, effective delegation decision.
Assigning this task to the AP is unrelated to a possible rapid change in the client’s condition.

D. Deliver a clean voided urine specimen to the laboratory.

Rationale: Knowing the client is an important criterion when making a safe, effective delegation decision.
Assigning this task to the AP is unrelated to a possible rapid change in the client’s condition.

22. An assistive personnel (AP) reports to the nurse that a client who returned to the unit following an abdominal
hysterectomy has a dressing which is saturated with blood. Which of the following tasks should be delegated to
the AP?

A. Changing the abdominal dressing

Rationale: Changing the abdominal dressing requires professional knowledge and skill which is an activity
that cannot be delegated by the nurse.

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B. Obtaining vital signs

Rationale: Obtaining vital signs is a skill for which the AP has been trained and it is within their job
description.

C. Palpating for possible bladder distention

Rationale: Palpating the client’s bladder requires professional knowledge and skill which is an activity that
cannot be delegated by the nurse.

D. Observing the incisional site

Rationale: Observing the incisional site requires assessment of the client’s condition which is an activity
that cannot be delegated by the nurse.

23. A charge nurse has assigned a group of clients to a newly licensed practical nurse (LPN). The charge nurse
observes the LPN chatting sociably with peers, learns that the LPN left the unit without communicating the
absence, and receives reports from clients about lack of care by the LPN. Which of the following is an appropriate
action by the charge nurse?

A. Review the LPN’s personnel file.

Rationale: Reviewing the LPN’s personnel file assists in understanding the LPN”S educational
background, but this is not an appropriate action at this time.

B. Discuss the LPN’s behavior with other nurses on the unit.

Rationale: Discussing the LPN’s behavior with other nurse on the unit clarifies the LPN’s performance, but
this is not an appropriate action at this time.

C. Review the LPN’s assignment in relation to other nurses on the unit.

Rationale: Reviewing the LPN’s assigned activities allows the charge nurse to see the delegated task from
the perspective of the LPN, and is the appropriate action at this time.

D. Reassign some of the nurse’s client care to assistive personnel.

Rationale: Reassigning the LPN’s client care to others does not clarify the LPN’s activities, and is not an
appropriate action at this time.

24. The nurse in a clinic is planning a community diabetes management program and developing goals for this
program. Which of the following is an appropriate goal?

A. Providers in the area will determine if clients are interested.

Rationale: Goals focus on the desired result toward which the activity is directed. This is an objective
because it identifies how the goal will be met.

B. Clients will have a decreased incidence of foot amputations.

Rationale: The goal focuses on the desired result toward which the effort is directed. A reduced incidence

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of foot amputations is an appropriate goal for a community diabetes management program.

C. A facility will be reserved for the program.

Rationale: Goals focus on the desired result toward which the activity is directed. This is an objective
because it identifies how the goal will be met.

D. Handouts and teaching materials will be distributed at the program.

Rationale: Goals focus on the desired result toward which the activity is directed. This is an objective
because it identifies how the goal will be met.

25. A nurse manager is reviewing safe delegation practices with nurses on the unit. Which of the following is an
appropriate statement by the nurse manager?

A. “All delegated task should be performed using outstanding skill.”

Rationale: Outstanding skill performance is not a principle of safe delegation practice.

B. “All delegated tasks require follow-up to ensure compliance.”

Rationale: Monitoring of performance to ensure compliance is a principle of safe delegation practice.

C. “All delegated tasks should be observed directly during task performance.”

Rationale: Performance of delegated skills is supervised but does not include direct observation of all
assigned tasks.

D. “All delegated tasks are stopped during poor task performance.”

Rationale: Intervention is only necessary if a task is being performed in a manner that jeopardizes client
safety. Performance evaluation should be discussed to improve future performance.

26. A new graduate nurse is making staff assignments. He assumes responsible for all clients needing IV medications
and high-level assessment skills and gives responsibility for the remaining clients to other personnel. This is an
example of which error in delegation?

A. Adopting familiar delegation patterns

Rationale: Adopting familiar delegation patterns frequently occurs but it is not an error in delegation.

B. Failure to provide delegation control

Rationale: Failure to provide delegation control is a management issue but not an error in delegation.

C. Underdelegating

Rationale: Underdelegating is an error in delegation and can indicate a desire by the nurse to complete
the whole job personally due to a lack of trust in subordinates; or a desire to show he can do a
better job than others.

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D. Unclear communication

Rationale: Unclear communication indicates failure to use an appropriate delegation strategy. It is not an
error in delegation.

27. A nurse is teaching the assistive personnel (AP) to set limits on a client’s manipulative behavior after the nurse has
reviewed the APs performance of a delegated task. Which of the following responses by the AP indicates further
teaching is needed?

A. “Consistency among staff is important.”

Rationale: Evaluation of performance should result in the AP understanding the positive aspects of task
performance.

B. “I will set limits each time I see a dysfunctional behavior.”

Rationale: Evaluation of performance should result in the AP understanding how the task should be
performed.

C. “I understand that limit-setting counteracts resistance.”

Rationale: Evaluation of performance should result in the AP understanding the outcomes to be achieved.

D. “The goal for the client is to ask directly for what he wants.”

Rationale: Evaluation of performance should focus on how the AP completed the task, not an evaluation
of client outcomes.

28. An RN is delegating care activities to a licensed practical nurse (LPN). Which of the following is the priority criteria
the RN considers when delegating?

A. Agency policies for the LPN

Rationale: The agency policies for the LPN are an important consideration when delegating, but they are
not the priority criteria.

B. The documented experience level of the LPN

Rationale: The documented experience level of the LPN is an important consideration when delegating,
but this is not the priority criteria.

C. The documented skill level of the LPN

Rationale: The documented skill level of the LPN is an important consideration when delegating, but this is
not the priority criteria.

D. State Nurse Practice Act for the LPN

Rationale: The state Nurse Practice Act for the LPN is the priority criteria to be considered when
delegating and guides agency policies, and the necessary experience and skill level of the
LPN.

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29. A nurse is planning to assign care activities to the assistive personnel (AP). Which of the following activities are
appropriate for assignment to the AP? (Select all that apply.)

A. Accompanying a client with depression to occupational therapy

B. Assessing a client with hypomania for exhaustion

C. Checking the position of a client in soft wrist restraints

D. Setting limits with a client who has mania

E. Sitting with a client who abuses alcohol whose last drink was two days ago

Rationale: Accompanying a client with depression to occupational therapy is correct. Accompanying a

client to occupational therapy is a skill for which the AP has received instruction.Assessing a
client with hypomania for exhaustion is incorrect. Assessment of a client requires specialized
knowledge and is an activity that cannot be delegated. Checking the position of a client in soft
wrist restraints is correct. Checking the position of a client in soft restraints is a skill for which
the AP has received instruction. The position can be reported to the nurse for follow-up. Setting
limits with a client who has mania is incorrect. Implementing the plan of care requires
specialized knowledge and is an activity that cannot be delegated. Sitting with a client who
abuses alcohol whose last drink was two days ago is correct. Sitting with a client is a skill for
which the AP has received instruction. Any changes in the client can be reported to the nurse
for follow-up.

30. A nurse has listened to a report at the start of the shift. Which of the following statements by the RN during this
report indicates that the nurse should assume total care for the client, rather than assigning tasks to the assistive
personnel (AP)?

A. “The client’s family members have been present most of the day.”

Rationale: The presence of family members is not a consideration in the decision to delegate tasks to
assistive personnel.

B. “The client’s blood pressure and pulse have been unstable.”

Rationale: Knowing the patient and the stability of his condition is a criterion to consider when delegating
to assistive personnel. To promote client safety, the more stable clients should be chosen when
delegating tasks to APs.

C. “The client discussed having prior thoughts of suicide.”

Rationale: The client having a history of suicidal ideation is not a criterion to consider when delegating to
assistive personnel.

D. “The client works in the hospital radiology department.”

Rationale: The client being an employee is not a criterion to consider when delegating to assistive
personnel.

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