Focus on Delegating Etc PDF

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1.ID: 9476872990  A registered nurse (RN) on the 7 a.m.–3 p.m. shift is planning client assignments for the day. Which clients would be appropriate for the RN to assign to the licensed practical nurse (LPN)? Select all that apply. A. A client who had a mastectomy 2 days ago Correct B. A client with type 1 diabetes mellitus who has a foot ulcer Correct C. A client with left-side weakness who will need assistance with personal care Correct D. A newly admitted client with chronic obstructive pulmonary disease E. 

(COPD) A client being transferred in from the intensive care unit with a deep

vein thrombosis and a heparin drip Rationale: When a nurse delegates aspects of a client’s care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. The client with COPD who was admitted during the night will need close monitoring of the respiratory status. An LPN may not administer most high-risk intravenous medications, including heparin. The client who has had a mastectomy and the client with a foot ulcer will likely require dressing changes, an activity that is within the scope of practice of the LPN. The client with left-side weakness requiring personal care assistance could also be

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assigned to the LPN. Test-Taking Strategy: Use the process of elimination, focusing on the subject, assignment to the LPN. Recalling that an LPN may not administer high-risk intravenous medications will assist you in eliminating this option. Eliminate the newly admitted client with COPD, noting that this client will require a higher level of monitoring. Review the principles of delegating tasks if you had difficulty

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with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Safety HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and

trends (8th ed., pp. 305, 308). St. Louis: Elsevier  Awarded 3.0 points out of 3.0 possible points. 2.ID: 9476871061  A home care nurse is assigned to visit a prenatal client with a diagnosis of hyperemesis gravidarum (HEG). During physical assessment of the client, the nurse should first: A. Weigh the client

B. Assess the client’s intake and output Correct C. Encourage the client to verbalize her feelings about the diagnosis D. Review the results of the hemoglobin and hematocrit 

determinations Rationale: HEG is persistent, uncontrolled vomiting that begins before the 20th week of pregnancy. It can have serious consequence, including loss of 5% of prepregnancy weight, dehydration, ketosis, acid-base imbalance, and electrolyte imbalances. Physical assessment begins with determining the client’s intake and output, because these data provide information regarding hydration and the nutritional status of the client. The client’s weight would be obtained and the baseline value compared with previous and subsequent values. Additionally, the nurse would instruct the client in how to accurately check and monitor her weight. Laboratory data may need to be evaluated; increased hemoglobin and hematocrit values may occur as a result of dehydration. Encouraging the client to verbalize her feelings about the diagnosis is a component of the plan of care but is not the first intervention

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during physical assessment. Test-Taking Strategy: Note the strategic word “first.” Use Maslow’s Hierarchy of Needs theory to eliminate the option that indicates encouraging the client to verbalize her feelings, recalling that physiological needs are the priority. To select from the remaining options, recall the description of HEG; this will direct you to the correct option. Review the priority physical assessment techniques in

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this disorder if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Nutrition HESI Concepts: Collaboration/Managing Care – Care Coordination, Nutrition Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013).

Maternal-child nursing (4th ed., pp. 589-590). St. Louis: Elsevier.  Awarded 1.0 points out of 1.0 possible points. 3.ID: 9476869315  A registered nurse (RN) on the night shift has a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP)on the team and is planning the client assignments for the night. Which client does the RN assign to the LPN? Select all that apply. A. A client who undergoing a 24-hour urine collection B. A client with a nasogastric tube who underwent bowel resection 2 days ago Correct C. A client with urinary frequency who needs assistance in getting to the bathroom

D. A client scheduled for renal dialysis in the morning who needs E. 

assistance with hygiene A client who has been fitted with skeletal traction of the right leg

after an open reduction measuresCorrect Rationale: When a nurse delegates aspects of a client’s care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. An LPN may perform certain invasive procedures. A client with a nasogastric tube who underwent bowel resection 2 days ago and a client in skeletal traction to the right leg after open reduction may safely be assigned to the LPN, because the LPN is capable of performing the nasogastric tube care, dressing changes, and monitoring for postoperative complications that the clients will require. Interventions such as assisting clients with ambulation and hygiene measures and performing noninvasive procedures — the types of tasks

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identified in the other options — may be assigned to a nursing assistant. Test-Taking Strategy: Use the process of elimination, focusing on the subject, assignment to an LPN. Eliminate the options that are comparable or alike in that they are noninvasive procedures. Also note that the remaining options involve routine care of the postoperative client and activities that are within the scope of practice for the LPN. Review the principles of delegation if you had difficulty with

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this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Safety HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013).

Fundamentals of nursing. (8thed., pp. 262, 281-283). St. Louis: Mosby.  Awarded 2.0 points out of 2.0 possible points. 4.ID: 9476867243  A nurse is monitoring a client with preeclampsia who is receiving intravenous magnesium sulfate to prevent seizures. The nurse notes that the client’s

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respiratory rate is 10 breaths/min. On the basis of this finding, the nurse first: A. Takes the client’s vital signs health care provider B. Contacts the health care provider C. Discontinues the magnesium sulfate Correct D. Checks the most recent serum magnesium sulfate level Rationale: A respiratory rate slower than 12 breaths/min is a sign of magnesium toxicity. Other signs include the absence of deep tendon reflexes, altered sensorium, hypotension, and a serum magnesium level above the therapeutic range of 5 to 8 mg/dL (2.05 to 3.29 mmol/L). In this situation, the nurse would first discontinue the magnesium sulfate. The nurse would then take the client’s

vital signs and contact the health care provider health care providerThe most recent serum magnesium level may be checked; however, a current serum level 

would provide more useful data. Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Recalling that a respiratory rate slower than 12 breaths/min is a sign of magnesium toxicity will direct you to the correct option. Review these signs

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and the appropriate nursing interventions if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013).

Maternal-child nursing (4th ed., p. 595). St. Louis: Elsevier.  Awarded 1.0 points out of 1.0 possible points. 5.ID: 9476864338  A client who has just undergone abdominal surgery calls the nurse and states, “I feel as if I just split open.” The nurse checks the abdominal incision and finds

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wound evisceration. The nurse immediately: A. Documents the findings B. Notifies the operating room C. Takes the client’s vital signs D. Contacts the health care provider Correct Rationale: Wound evisceration is the total separation of a surgical incision or wound with extrusion of the internal organs or viscera through the open wound. When evisceration occurs, the nurse immediately calls for help and has the health care provider notified. The nurse stays with the client and positions the client with the hips and knees bent. The nurse then covers the abdominal wound with a sterile dressing moistened with sterile saline solution. The nurse would then take the client’s vital signs and document the occurrence. Since this is a surgical emergency, the operating room would be notified but this would not

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be done until directed to do so by the surgeon. Test-Taking Strategy: Use the process of elimination and your prioritizing skills. Note the strategic word “immediately.” Recalling that wound evisceration is a surgical emergency will direct you to the correct option. Review the nursing actions to be taken immediately in the event of wound evisceration occurs if you

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had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment,

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Caregiving HESI Concepts: Clinical Decision-Making/Clinical Judgment, Cargiving

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Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th

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ed., p. 180). St. Louis: Mosby.  Awarded 1.0 points out of 1.0 possible points. 6.ID: 9476874711  A client is receiving an intravenous (IV) infusion of 1000 mL of normal saline solution at a rate of 125 mL/hr. The client suddenly complains of shortness of breath, and the nurse notes the presence of dependent edema and puffiness around the client’s eyes. The nurse suspects circulatory overload and

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immediately: A. Slows the IV rate Correct B. Administers a diuretic C. Contacts the health care provider D. Places the client in a supine position Rationale: Signs of circulatory overload include shortness of breath, cough, increased blood pressure, puffiness around the eyes, and edema in dependent areas. The client’s neck veins may be engorged, and the nurse may hear moist breath sounds on auscultation of the lungs. If circulatory overload occurs, the nurse must immediately slow the IV rate and then notify the health care provider. The client would be placed in an upright position. The nurse would monitor the client’s vital signs and administer oxygen and diuretics as

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prescribed. Test-Taking Strategy: Focus on the data in the question and note the strategic word “immediately.” Eliminate the option in which the client is place in a supine position, because this position will exacerbate the existing shortness of breath. Recalling that administration of a diuretic requires a health care provider’s prescription will assist you in eliminating this option. To select from the remaining options, focus on the strategic word and note that circulatory overload is suspected; this will direct you to the correct option. Review the interventions to be taken immediately when circulatory overload is suspected if

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you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Intravenous therapyGiddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing:

Patient-centered collaborative care. (7th ed., p. 230). St. Louis: Saunders.  Awarded 1.0 points out of 1.0 possible points. 7.ID: 9476864386  A nurse is performing closed suctioning through a tracheostomy for a ventilatordependent client. During the procedure, the alarm on the cardiac monitor

sounds and the nurse notes severe bradycardia. The nurse stops suctioning the

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client and immediately: A. Contacts the respiratory therapist B. Rechecks all ventilator connections C. Oxygenates the client manually with 100% oxygen Correct D. Increases the degree of PEEP the client is receiving Rationale: Suctioning is associated with several complications, including hypoxia, tissue (mucosal) trauma, infection, vagal stimulation, and bronchospasm. Vagal stimulation may result in severe bradycardia, hypotension, heart block, ventricular tachycardia, or asystole. If vagal stimulation occurs, the nurse stops suctioning immediately and oxygenates the client manually with 100% oxygen. Contacting the respiratory therapist will delay the required and immediate intervention. Although regular checks of the ventilator connections are the standard of care for a client undergoing mechanical ventilation, doing so will not alleviate the client’s problem in this

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situation. An increase in PEEP is not indicated at this time. Test-Taking Strategy: Focus on the data in the question and note that the client is exhibiting severe bradycardia. Use your knowledge of the ABCs — airway, breathing, and circulation. This will direct you to the correct option. Review the complications associated with suctioning and the immediate nursing

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interventions if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas

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Exchange Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th

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ed., p. 1623). St. Louis: Mosby.  Awarded 1.0 points out of 1.0 possible points. 8.ID: 9476867288  Inner maxillary fixation (IMF) is performed on a client who sustained a mandibular fracture in a motor vehicle crash. During an assessment, the client begins to vomit. The nurse suctions the client but is unsuccessful, and the client

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exhibits signs of hypoxia. The nurse immediately: A. Cuts the mouth wires Correct B. Administers an antiemetic C. Contacts the anesthesiologist D. Places the client is a supine position Rationale: IMF is a common means of securing a mandibular fracture. The bones are realigned and then wired in place with the bite closed. After surgery, the client is at risk for aspiration if he or she vomits because of the impossibility

of opening the jaws to allow ejection of the emesis. If vomiting occurs, the nurse would attempt to suction the client. If suctioning is unsuccessful, the wires are cut. Wire cutters are kept with the client at all times in readiness for this emergency. Antiemetics may be prescribed to prevent nausea and subsequent vomiting; however, this is not the immediate action if the client is vomiting. Placing the client in a supine position increases the risk of aspiration. The client is placed in an upright position and turned to the side. There is no helpful 

reason to contact the anesthesiologist. Test-Taking Strategy: Use the process of elimination and visualize this surgical procedure. Noting that the client is vomiting and recalling that aspiration is a risk in this situation will direct you to the correct option. Review care of the client

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after IMF if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas

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Exchange Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th

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ed., pp. 1529-1530). St. Louis: Mosby.  Awarded 1.0 points out of 1.0 possible points. 9.ID: 9476869352  A child arrives at the emergency department experiencing anaphylaxis after

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being stung by a bee on the right arm. The nurse should first: A. Call a code B. Start an intravenous (IV) line C. Initiate cardiopulmonary resuscitation (CPR) D. Place a tourniquet proximal to the site of the insect sting Correct Rationale: Anaphylaxis is a severe immediate hypersensitivity reaction to an excessive release of chemical mediators. Treatment of anaphylaxis must be started immediately, because it may be only a matter of minutes before the child experiences shock. The nurse would immediately take steps to ensure an adequate airway, place a tourniquet just proximal to the site of the insect sting to help confine the allergen, administer epinephrine (medication of choice) as prescribed, administer oxygen, administer corticosteroids and antihistamines as prescribed, keep the child warm and lying flat or with the feet slightly elevated,

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and start an IV line. Test-Taking Strategy: Note the strategic word “first” and use the skills of prioritizing to answer the question. Recognizing that there is no information in the question that indicates that CPR is necessary will assist you in eliminating the options that are comparable or alike (calling a code and initiating

cardiopulmonary resuscitation). To select from the remaining options, visualize the situation and note the relationship between the situation and the correct option. Review the interventions to be taken immediately in the event of

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anaphylaxis resulting from a bee sting if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Critical Care Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas

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Exchange References: Hammond, B., & Zimmermann, P. (2013) Sheehy’s Manual of

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Emergency Care (7th ed., p. 351). St. Louis: Elsevier. Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and

children (10th ed. pp....