NACE Management of Care 4 — Questions and Answers
Question 1: A nurse is preparing to delegate the task of ambulating a post-operative patient to an unlicensed assistive personnel (UAP). Which action is most important before delegation?
- Ensure the UAP has been trained and is competent to perform the task (Correct answer)
- Inform the charge nurse of the delegation decision
- Document the delegation in the patient's chart first
- Ask the patient's family if they approve of the UAP performing the task
Correct answer: Ensure the UAP has been trained and is competent to perform the task
Before delegating, the nurse must verify that the UAP has the training and competency to safely perform the specific task.
Question 2: A PN is caring for four patients. Which patient should be assessed first?
- A patient requesting a pain medication refill rated 4/10
- A patient who became suddenly confused and restless one hour post-surgery (Correct answer)
- A patient awaiting discharge instructions for diabetes management
- A patient with a stable wound dressing that needs to be changed
Correct answer: A patient who became suddenly confused and restless one hour post-surgery
Acute onset confusion and restlessness post-surgery may indicate hemorrhage, hypoxia, or other life-threatening complications requiring immediate assessment.
Question 3: Which action by the nurse best demonstrates the use of the chain of command?
- Asking a colleague to assist with a difficult procedure
- Reporting a physician's unsafe order to the nursing supervisor after the physician refuses to change it (Correct answer)
- Consulting the pharmacist about a medication interaction
- Calling the patient's family to discuss discharge plans
Correct answer: Reporting a physician's unsafe order to the nursing supervisor after the physician refuses to change it
The chain of command is used when a concern cannot be resolved at the current level; escalating an unresolved unsafe order to the supervisor is the correct use.
Question 4: A nurse is orienting a new graduate nurse and observes her document an assessment she did not perform. What is the nurse's priority action?
- Remind the new nurse to complete all assessments on time
- Report the falsified documentation to the charge nurse or supervisor immediately (Correct answer)
- Add a late entry to the chart correcting the record
- Counsel the new nurse privately and allow her to self-correct
Correct answer: Report the falsified documentation to the charge nurse or supervisor immediately
Falsifying documentation is a serious legal and ethical violation that must be reported immediately to a supervisor.
Question 5: When using SBAR communication during a hand-off report, what information belongs in the 'Background' section?
- The nurse's recommended plan of care for the next shift
- The patient's current vital signs and chief complaint
- Relevant medical history, admitting diagnosis, and current medications (Correct answer)
- The nurse's assessment of the patient's current status
Correct answer: Relevant medical history, admitting diagnosis, and current medications
Background includes pertinent clinical history such as admitting diagnosis, relevant past medical history, and current medications.
Question 6: A nurse discovers a patient left the unit without notifying staff (elopement). What is the priority nursing action?
- Search the facility and notify the charge nurse and security immediately (Correct answer)
- Document the absence in the chart and wait 30 minutes
- Call the patient's emergency contact before notifying security
- Complete an incident report before taking any other action
Correct answer: Search the facility and notify the charge nurse and security immediately
Patient elopement is a safety emergency; the nurse must immediately alert the charge nurse and security to initiate a search.
Question 7: A nurse is preparing a patient for surgery and realizes the informed consent form is unsigned. The patient states they are ready to proceed. What should the nurse do?
- Proceed with preoperative preparation since the patient verbally consented
- Notify the surgeon and delay the procedure until written informed consent is obtained (Correct answer)
- Have the patient sign the form immediately and proceed
- Document the verbal consent and continue with preparations
Correct answer: Notify the surgeon and delay the procedure until written informed consent is obtained
A signed informed consent form is legally required before surgery; the nurse must notify the surgeon and halt the procedure until it is properly obtained.
NACE Management of Care 4
A nurse is preparing to delegate the task of ambulating a post-operative patient to an unlicensed assistive personnel (UAP).
Which action is most important before delegation?