ANSWER KEY. Chapter 1. Opening Scenario. Keep Your Patients Safe 1-1. Keep Your Patients Safe 1-2. Case Study 1-1

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1 ANSWER KEY Chapter 1 Opening Scenario The nurse is responsible for all aspects of a patient s care. The NAP s role consists of completing all tasks given to her within her job description. The nurse must explain all tasks given to the NAP. Assuming that the NAP is the person who put the weights on the floor, the nurse should have verified that the NAP had the ability to remove a bedpan, obtain a urine sample, and care for a patient with a fractured hip in Buck s traction. If the patient removed the traction herself, she should be reoriented to the need to keep the traction on at all times. Prevent future problems with good communication between RN, NAP, and the patient. Keep Your Patients Safe 1-1 When you complete the assignment sheet in Figure 1-2, you will fill in all information requested for the five patients that you have selected. You will assign patient care to the RN, LPN/LVN, or NAP, based on state law, nursing standards, and staff competence. Keep Your Patients Safe 1-2 Yes, the charge nurse has the authority. The rationale is that the charge nurse is aware of the competency of the new nurse and has assessed this new nurse s ability. Case Study 1-1 Frequently when a new nurse or employee tries to fit in amongst fellow employees, he or she acts similar to the group. This approach to becoming accepted is not always effective or ethical. The new RN should refer to the NAP by name. Developing a respectful working relationship with everyone X_01_ANS_p indd 1

2 2 Answer Key working on the unit develops trust. The trust can then be transferred to the making of assignments and delegation. As the nurse preceptor is helping a new nurse become familiar with all of the health team members, inappropriate comments should be dealt with by the nurse preceptor or manager, as appropriate. If the NAP needs feedback about poor performance, it must be given by the appropriate RN in a timely fashion. Case Study 1-2 One possible evaluation is this: After talking with Mr. Glusak, he says he feels better and decides to go home. The next day, he thanks you for taking the time to talk with him. He tells you that he appreciated the rest, as well as the good care his wife is receiving. Review Questions 1. A, B, C, D 2. D 3. A, B, C, D 4. D 5. C 6. C 7. D 8. A 9. A 10. C 11. C Apply Your Skills 1. This article identifies several elements of organizational accountability. 2. This discussion may help you clarify the importance of sound delegation practices. 3. You may have noted some of the delegation obstacles on your patient care unit. 4. This exercise often helps you clarify your thinking. Chapter 2 Opening Scenario 1. Tasks to delegate to the NAP include: taking vital signs, assisting patients with baths (setting up water, providing towels), changing linens, and 8178X_01_ANS_p indd 2

3 Answer Key 3 sitting with patients and playing a game, to name a few. The ultimate responsibility and accountability for the overall care of the patient remains with the RN. The RN will apply the Five Rights whenever deciding to delegate. The NAP must follow the standards of care for all patients. The RN must be sure that the NAP is clear on the standards and monitor and evaluate care on an ongoing basis. The RN must also re-evaluate the patient on an ongoing basis to assure patient safety, especially if a patient periodically complains of dizziness. Keep Your Patients Safe 2-1 As you work with these patients and staff, you need to problem-solve all issues using the questions of the Delegation Decision-Making Tree and the Five Rights of Delegation. Sometimes you may need to change your initial decision based on the changing status of patients and staff. Keep Your Patients Safe 2-2 Identify which members of the health care team may do each of the following nursing activities. Nursing Activity RN LPN/LVN NAP Administer blood to a patient. X Assess a patient going to surgery. X Develop a teaching plan for a patient newly diagnosed with diabetes. X Measure a patient s intake and output. X X X Give a bath to an immobilized patient. X X X Perform a dressing change on a patient. X X Give patient report when transferring a patient from the ICU to a step-down unit. X Administer insulin. X X Evaluate a patient s DNR status. X Give an oral medication. X X Assist a patient with ambulation. X X X Give an IM pain medication. X X 8178X_01_ANS_p indd 3

4 4 Answer Key Keep Your Patients Safe 2-3 You and your staff may hold some of these cultural values. Discuss these values with staff, as appropriate, and work together toward the goal of increased tolerance for all cultural values. Case Study 2-1 The nurse should clearly tell the NAP the requirements at the start of the shift, both verbally and in writing. The nurse should send the NAP to complete his or her I&O if this is the first time this problem has occurred. If this problem has occurred before, the nurse should counsel the NAP and use the chain of command to report any problems, as appropriate. The NAP is likely to repeat the inappropriate performance if he or she is not counseled. Your decisions will be guided by your state nurse practice act, your organization s policies, and many other factors. Review your answers with the other nurses that you work with. Review Questions 1. A, B, D 2. B, C, D 3. A 4. D 5. A 6. D 7. A 8. B 9. D 10. C 11. B 12. B Apply Your Skills 1. You will choose your answer based on the education and experience of Jill and Penny. Also review the Five Rights of Delegation and the Delegation Decision-Making Tree as you decide. 2. Administering medications, flushing IV lines, turning IV pumps off or silencing them, applying medicated cream, and any other task that only a nurse is allowed to perform are examples of inappropriate delegation to the nursing student working as NAP. The only time that a nursing student can legitimately perform these tasks is during his or her clinical rotation with faculty supervision. 8178X_01_ANS_p indd 4

5 Answer Key 5 3. a. Although something as simple as measuring abdominal girth may seem easy to delegate, it is important to get an accurate measure of any ascites. This delegation decision depends on how well the nurse knows the capabilities of the NAP. This task may be done by NAP if the nurse feels comfortable that the NAP has the competency, education, and skill to do it. The nurse must evaluate all delegation on an ongoing basis. b. Initially, the nurse needs to explain why the patient needs to be NPO for these tests. The patient may have specific questions that the RN can answer. c. Yes, this is acceptable for the NAP to perform as long as the NAP has the competency, education, and skill to do it. d. The NAP may check on the patient. The patient has just received devastating news, and having someone to talk to could be beneficial. As always, the NAP must have the competency, education, and skill necessary for the task, or the RN must intervene. The RN may also want to talk with the patient when time allows. Chapter 3 Opening Scenario Sometimes new nurses think, Oh no, I have to do something to save this patient. I do not want my patients to die. But more experienced nurses who are familiar with patients like this whom they have taken care of over the years understand that when patients say such things, they may be tired of being hospitalized and unable to do what they used to do. Patients often need to verbalize these thoughts to decrease their anxiety. Utilize the communication skill of clarifying and restate what the patient said for example, You don t think you are going to make it? Do not be judgmental about the patient s decisions. Demonstrate caring and provide additional resources for the patient and his wife, including social services and perhaps hospice. Clarify with the health care providers what the patient s resuscitation status is, for example, Do Not Resuscitate (DNR). Keep Your Patients Safe 3-1 The RN did not include Mr. Jones full name, room, and bed number in the information given to the NAP. This resulted in the NAP going to the wrong room, where the other Mr. Jones was located. The NAP did not know there were two patients with the same name on the unit. If two patients with the same or a very similar name are on the same unit, they should not be assigned to the same nurse or to the same NAP. A name alert sticker should be on all patient s charts, belongings, etc., 8178X_01_ANS_p indd 5

6 6 Answer Key when two patients have the same last name. Additionally, the nurse should always include the room and bed number as well as the patient s name when referring to a patient. Using the patient s first and last names for identification will also be useful. The nurse should admit to the NAP that he or she did not provide the NAP with complete and detailed information. The nurse should also encourage the NAP to clarify any patient care instructions when information is incomplete. If both persons work to ensure that information is complete, quality patient outcomes will improve. Keep Your Patients Safe 3-2 You may agree or disagree with Wiseman s findings. Your decision may be affected by the degree of environmental control you believe that you have over your life. Your beliefs about your luck may affect your goal setting, your nursing career, and your life. Case Study 3-1 Teamwork on the unit allows the nurse to delegate patient care as appropriate and maintain patient safety. The standard routine for the adult patients listed at the front of the book might look like this. 7:00 a.m. Handoff shift report from night shift to day shift 7:15 a.m. Charge nurse reviews patient care assignments with all nurses and unit staff; goals and priorities are set 7:20 a.m. Ongoing assessment begins, e.g., assess patients ABCs, safety, comfort, infection control, vital signs, neuro checks, cardiac monitor rhythms, and diagnostic tests needed; maintain IV fluids, pass fresh water, keep siderails up, maintain psychiatric patients safety, maintain traction, arrange for social services to see psychiatric and obstetric patients, etc. 7:30 a.m. Breakfast 7:45 a.m. A.M. care with bathing begins following nursing care standards and unit routines 8:00 a.m. Give medications; medical and nursing practitioners make rounds; review all new orders; complete diagnostic tests and documentation; turn, cough, and deep breathe patients every two hours and check their breath sounds, bowel sounds, and voiding; keep patients legs moving; ambulate patients, etc. 11:30 a.m. Ongoing assessment of vital signs, neuro checks, cardiac monitor, patient safety, etc. 12:00 p.m. Lunch; give medications 2:00 p.m. Intake and output reports, documentation completed 3:00 p.m. Handoff shift report from day shift to evening shift 8178X_01_ANS_p indd 6

7 Answer Key 7 Case Study 3-2 The Myers-Briggs Type Indicator would give you more information about the members of this team. See the online test in the Web exercises of this chapter. Review Questions 1. B 2. B 3. D 4. C 5. B 6. A 7. D 8. C Apply Your Skills 1. Give the nursing activities to the NAP both verbally and in writing. Avoid the barriers to communication listed in this chapter, and use eye contact when talking with the NAP. Offer help to the NAP whenever you can. Consider sharing a cup of coffee or a snack together at the end of the day. 2. Introduce yourself every time you encounter a new person. Use good eye contact. Ask questions when appropriate, and seek clarification if unclear. Use the SBARR technique to organize information if you need to call another health care provider for help with a patient. Remind the supervisor that this is your first time to be a team leader. Ask for help, as needed. 3. Did the results of your personality inventory match the personality type that a friend or colleague thinks you are? This information can give you insight into your communication with others. 4. Mary needs to review the state nurse practice act, the Delegation Decision-Making Tree, the Five Rights, and use the four Cs that characterize good communication, which include Clear, Concise, Correct, and Complete communication in working with the NAP and other unit staff. 5. Table 3-4 should be considered mandatory for all nurses to utilize in developing their professional nursing role. 8178X_01_ANS_p indd 7

8 8 Answer Key Chapter 4 Opening Scenario Lateisha should send the NAP to safeguard Mrs. Glusak while Lateisha assesses the new surgical patient. It is helpful for Lateisha to use the ABCs to prioritize patient care. Lateisha can manage her time and set priorities by coming to work a little early, reviewing patient needs, and setting priority goals for the shift. Keep Your Patients Safe 4-1 Nurses and others often have more time than they think they do. It is helpful to complete an activity log to identify how you use your time. This can serve as a basis for setting time management goals and outcomes for the future. Identify your outcome goals and manage your time to achieve them. Keep Your Patients Safe 4-2 Your assessment skills will improve as you practice this approach, i.e., First Look, then ABCD. Case Study 4-1 Your clinical unit s routine and teamwork may vary depending on the type of patients cared for. Complete the sample below. 7:00 a.m. 7:15 a.m. 7:30 a.m. 7:45 a.m. 8:00 a.m. 9:00 a.m. 10:00 a.m. 11:00 a.m. 11:30 a.m. 12:00 p.m. 1:00 p.m. 2:00 p.m. 3:00 p.m. 8178X_01_ANS_p indd 8

9 Answer Key 9 Case Study 4-2 Use the form below. Consider each staff member s competence, strengths, and weaknesses as you delegate. Consider what is happening on other units of the hospital. Consider what standards and orders must be implemented. Plan to evaluate all patient and staff outcomes and adjust assignments on an ongoing basis. ASSIGNMENT SHEET EXCERPT Unit Date Shift Charge nurse RNs Breaks/Lunch LPN/LVNs Breaks/Lunch NAP Breaks/Lunch Notify RN immediately if: T <97 or >100 P <60 or >110 R <12 or >24 SBP <90 or >160 DBP <60 or >100 BS <70 or >200 Pulse oximetry <95% Urine output < 30 cc/hour Notify RN one hour prior to end of shift: I&O Patient goal achievement Narcotic Count Glucometer Check Pass Water Stock Linen Medication Refrigerator Temperature Check Other Room Patient Staff A.M./P.M. Care Weight I&O IV Activity Glucometer Tests NPO Comments 8178X_01_ANS_p indd 9

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11 Answer Key 11 Keep Your Patients Safe 4-3 Again, the patient with the airway problem who is nonresponsive and drooling is seen first. Of course, the patient with absent breath sounds on the right side of his chest would be seen next. It is best that more than one nurse be available to work with these three patients. Review Questions 1. C 2. C 3. C 4. A 5. A 6. C 7. C 8. A 9. C 10. B 11. A 12. B 13. C 14. A 15. B Apply Your Skills 1. When the sitter asks for a break, you can delegate the sitter s role to the NAP. However, you must always take the time to assess the NAP s education, experience, competency, and reliability to do delegated tasks prior to delegating them. At times, you may assess the situation and ask all personnel to postpone breaks until patient safety is assured; you may need to ask the nursing supervisor for help. 2. Priority Assessment Mr. M. G. ABCs, vital signs, pain, cardiac monitor, IV line, oxygen. See this patient first. Mrs. L. G. ABCs, vital signs, level of consciousness, IV line, safety, family support. See this patient second. Mrs. N. J. ABCs, vital signs, safety, comfort, teaching. See this patient third. It is best if there is more than one nurse to care for these three patients. 8178X_01_ANS_p indd 11 3/18/10 10:36:27 PM

12 12 Answer Key 3. Were you torn between the patient with CHF and the other patients? Remember, you must assess ABCs first, then safety, then comfort, and then teaching. See Mrs. L. G. second and Mrs. N. J. third. 4. Use the Activity Log in this chapter. Were you surprised at how you use your time? Study the completed activity log and determine any changes you would like to make to assure that 20% of your time achieves 80% of your goals. 5. Use the Activity Log to identify your current activities and set your goals. Chapter 5 Opening Scenario Colleen must stop the IVPB infusion STAT and then check the patient s vital signs and ABCs. Colleen should hang an IV of normal saline to keep the vein open in case of emergency. Colleen should make out an incident report and notify the nursing supervisor and the health care provider. The hospital pharmacy and the nursing unit should review the labeling of the medication to identify the need for additional labeling safeguards. They may consider the use of computerized patient and medication identification methods to prevent future errors. A problem like this can be the fault of both the hospital system and the nurse involved. Keep Your Patients Safe 5-1 Nurses have a duty to protect the health and safety of their patients. When a nurse encounters a colleague with a potential impairment, such as drug or alcohol abuse, the nurse must take appropriate action to ensure that the impaired colleague is not endangering patients. All nurses, whether novice or experienced, should relay concerns about their colleagues to their nurse manager. In most states, nurses also have an obligation to report the colleague to the state board of nursing. Prior to such an action, nurses may want to consult an attorney regarding their obligations. Many states offer nonpunitive treatment programs to encourage impaired nurses to seek help. Keep Your Patients Safe 5-2 Note that the hospital has a responsibility to provide quality care to all of its patients. Even though you have never worked in critical care, you can help deliver patient care with the more experienced staff s supervision. You can take 8178X_01_ANS_p indd 12 3/18/10 10:36:27 PM

13 Answer Key 13 vital signs, provide comfort care, and so on. Be sure to demonstrate cooperative behavior. Be sure also to alert staff and your manager when you are unable to perform a nursing action because you are not prepared to do so. You cannot assume responsibility for these critically ill patients safely by yourself. Case Study 5-1 The nurse must never execute an order that he or she knows to be dangerous. In the event that a medication order is incorrect or incomplete and the nurse cannot locate the health care provider, the nurse should go through the hospital s chain of command to correct the order. The new nurse will find it helpful to start with his or her nurse manager to help navigate the hospital s chain of command. A discussion of the medication with the hospital pharmacist may also be helpful. Case Study 5-2 Review placebo administration from the point of view of each of the ethical principles discussed in this chapter. What does your analysis prescribe for your nursing actions? Did the discussion of pros and cons alter your decision making? Keep Your Patients Safe 5-3 It may not be possible to deliver these medications safely in the prescribed time frame. The problem may include the geography of the unit as well as such things as patient inability to swallow. Note that in many organizations, you have 45 minutes on either side of the time to give the medications. This gives you ninety minutes. Notify your supervisor that you will probably not be able to give all medications within the prescribed time frame. Prioritize and give the most important medications within this time frame. Give the other medications as soon as you can. Be sure to alert the oncoming shift so that they know not to give any medications too soon after the first dose. Alert your supervisor, and make out an incident report so that the nursing home can review its policies and staffing for the future. If improvement does not occur, you may have to leave the agency to avoid giving unsafe care. Review Questions 1. A 2. C 3. D 8178X_01_ANS_p indd 13 3/18/10 10:36:27 PM

14 14 Answer Key 4. C 5. B 6. C 7. C 8. B 9. B 10. C 11. B 12. C Apply Your Skills 1. The Risk Manager usually investigates all incident reports. This investigation is used to uncover system problems as well as individual problems. The investigation may identify the need to take action either with an individual practitioner or with the entire organization to prevent future problems. 2. Nurses faced with a dangerous medication order often start their problem-solving process by checking a medication textbook and talking to the pharmacist. If the nurse still thinks medication is a problem, he or she should call the health care provider for clarification/ resolution. If the problem persists, the nurse should discuss the situation with the nursing supervisor and may need to refuse to give the medication and notify the health care provider. This process must be documented and may require consultation with additional nursing and medical administration, such as the director of the medical staff and the director of the nursing staff, to assure patient safety. 3. Several companies offer nursing malpractice insurance. A large insurer is the Nursing Service Organization (NSO). NSO s Web site ( offers information about its insurance products, as well as case studies describing recent nursing legal actions. 4. Your state Web site may offer useful information for your review. Monitor your state s Web site to note any changes in your state s nurse practice act. Chapter 6 Opening Scenario Anwar can prepare for the exam by identifying his weak knowledge areas using Table 6-3. He then can set up a study schedule of one to two hours daily, focusing on areas of knowledge weaknesses. He can decrease his 8178X_01_ANS_p indd 14 3/18/10 10:36:27 PM

15 Answer Key 15 anxiety by exercising regularly, thinking positively, avoiding negative people, practicing relaxation exercises, and listening to relaxing music. He can review nursing content and practice taking test questions in all of the NCLEX knowledge areas. This will help him prepare for NCLEX in the three areas of test preparation; possessing the knowledge, becoming adept at testing, and controlling test anxiety. Keep Your Patients Safe 6-1 How well did you do on the indicators of being a professional nurse? Be sure to measure them regularly. Did you add any indicators to the list? Case Study 6-1 After you analyze your NCLEX-RN learning needs, identify your best time to study. You may realize you are a morning person or a night person, that is, you concentrate better at one of these times. Accordingly, choose a morning or evening time, and identify one hour a day to practice test questions in your weak content areas. Review the rationales of any questions you miss. Use several different review books from various authors and publishers to practice test questions. If you practice 60 questions daily for 30 days, you will practice 1,800 questions. Review the rationales and practice all areas of the test plan. You are increasing your likelihood of doing well on NCLEX. If you are freshest to study in the morning, your chart might look like this: M T W R F S S 8:00 9:00 a.m. X X X X X X X 9:00 10:00 a.m. 10:00 11:00 a.m. 11:00 12:00 p.m. 12:00 1:00 p.m. 1:00 2:00 p.m. 2:00 3:00 p.m. 3:00 4:00 p.m. 4:00 5:00 p.m. (continues) 8178X_01_ANS_p indd 15 3/18/10 10:36:27 PM

16 16 Answer Key (continued) 5:00 6:00 p.m. 6:00 7:00 p.m. 7:00 8:00 p.m. 8:00 9:00 p.m. 9:00 10:00 p.m. Be sure to build time into your study chart every Monday to check the NCSBN Web site for the question of the week. Case Study 6-2 The RN can assist Nirmala in her NCLEX-RN test preparation by helping her concentrate on the three areas of test preparation; knowledge, anxiety management, and test-taking. Review Questions 1. A 2. D 3. C 4. A 5. D 6. B 7. C 8. A 9. C 10. B 11. D 12. D 13. A 14. C Apply Your Skills 1. How did you do? Practice test questions in different review books until you are doing well on all areas of NCLEX. 2. When you review the test plan, consider practicing test questions in all areas of the test plan. 8178X_01_ANS_p indd 16 3/18/10 10:36:27 PM

17 Answer Key Many students find the multiple response test items that require more than one response difficult, as well as the fill-in-the-blank questions and the hot spot questions that ask the test-taker to identify an area on a picture or a graphic. 4. Your exit exam or comprehensive exam will probably identify areas of the NCLEX test plan, as well as areas such as adult or pediatric health, maternal child health, and mental health, for further review. Practice test questions until you are doing well in all areas of the NCLEX test plan. 5. The Medication Study Excerpt is a good place to start strengthening your medication knowledge. 8178X_01_ANS_p indd 17 3/18/10 10:36:27 PM

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