Prioritization and Delegation (PASS Integration)
After undergoing a cardiac catheterization, a client has a large puddle of blood under his buttocks. What is the nurse's priority action? Call for help Obtain vital signs Ask the client to "lift up" Assess the groin site
Assess the groin site Explanation: Assessment of the groin site is the priority. This establishes the source of the blood, and determines how much blood has been lost. The goal is to stop the bleeding. The nurse would call for help if needed after the assessment of the situation. After determining the extent of the bleeding, vital sign assessment is important. The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause re-bleeding.
What is the priority nursing action for a client with generalized anxiety disorder who is working to develop coping skills? Determine whether the client has fears or obsessive thinking Monitor the client for overt and covert signs of anxiety Teach the client how to use effective communications skills Assist the client to identify coping mechanisms used in the past
Assist the client to identify coping mechanisms used in the past Explanation: To help a client develop effective coping skills, the nurse must know the client's baseline functioning. Determining whether the client has fears or obsessive thinking, monitoring for signs of anxiety, and teaching about effective communications skills are later priorities.
The nurse is delegating activities to a recently graduated licensed practical/vocational nurse (LPN/VN) at a skilled nursing facility. Which activities are appropriate to delegate to the LPN/VN? Select all that apply Cleansing a leg wound and applying antibiotic ointment. Administering intravenous sedation. Completing an admission body assessment. Recording percentage of meal completion. Assisting an unlicensed assistive personnel (UAP) with a weight.
Explanation: According to the LPN/VN scope of practice, the LPN/VN can cleanse a leg wound and apply antibiotic ointment, record percentage of meal completion, and assist a UAP with weighing a client. The scope of practice of a LPN/VN varies by state, but it usually does not include administering an intravenous medication unless the nurse has obtained a certification establishing competency with IV medication administration. Even then, administering a sedative may be outside the scope of practice. An admission body assessment must be performed by an RN.
A nurse is caring for a 2-year-old client, who weighs 25 lb (11.3 kg), and has a fractured femur. What is the nurse's priority assessment for this client? length of one leg to the other affected leg distal to the fracture affected leg anterior to the fracture affected leg proximal to the fracture
affected leg distal to the fracture Explanation: The nurse should focus the assessment on the area distal to the fracture. This area is most at risk for neurovascular compromise. If a fracture severs or obstructs blood vessels or nerves, blood flow is disrupted distal to the site, and may lead to nerve or tissue damage. The unaffected leg should be used for baseline comparison. This client should be assessed for the five "Ps:" pulse, pallor, paresthesia, pain, and paralysis.
A child has ingested a bottle of over-the-counter medication and is brought into the emergency department by the parents. The nurse expedites rapid first aid for poisoning by immediately accessing what resource? contacting the Poison Control Center by phone reviewing the treatment for overdose on the medication bottle reviewing the emergency department poison control guidelines consulting the current Compendium of Pharmaceuticals and Specialties (CPS)
contacting the Poison Control Center by phone Explanation: Despite having directions on the bottle or in the CPS about what to do in the event of overdose of medications, best practice dictates the nurse contact the Poison Control Center for directions. Often, medication labels are outdated and should not be followed. Written hospital guidelines may also be out of date. Although making the call takes time, it guarantees the best treatment for the poisoning.
