Capstone Prioritization and Delegation
An elderly client is being monitored for evidence of congestive heart failure. To detect early signs of heart failure, the nurse would instruct the certified nursing attendant (CNA) to do which of the following during care of the patient? 1. Observe electrocardiogram readings and report deviations to the nurse. 2. Assist the client with ambulation three times during the shift. 3. Monitor vital signs every 15 minutes and report each reading to the nurse. 4. Accurately weigh the patient, and report and record the readings.
4. Accurately weigh the patient, and report and record the readings. Rationale: Due to fluid accumulation, an expanded blood volume can result when the heart fails. Body weight is a sensitive indicator of water and sodium retention, which will manifest itself with edema, dyspnea - especially nocturnal - and pedal edema. Patients also should be instructed about the need to perform daily weights upon discharge to monitor body water. It is not within the role of the CNA to monitor ECG readings, and ambulation is not an assessment. Vital signs every 15 minute are not necessary for this level of patient care.
The nurse is seeing patients in the medical/surgical unit. Which of the following patients should the nurse see FIRST? 1. A patient diagnosed with heart failure who has received 800 ml of IV fluids in 2 hours. 2. A patient diagnosed with lung cancer with a blood calcium level of 10.5 mg/dL. 3. A patient diagnosed with hypertension requiring the 9 A.M. dose of captopril (Capoten). 4. A patient postoperative after a laminectomy who requires supervision when ambulating.
1. A patient diagnosed with heart failure who has received 800 ml of IV fluids in 2 hours. Assess for circulatory overload.
The nurse receives report on the medical/surgical unit. Which of the following clients should the nurse see FIRST? 1. A client with an IV of normal saline infusing at 125 ml per hour complaining of slight swelling at the IV insertion site. 2. A client 3 days post right knee replacement complaining of right calf pain with movement. 3. A client with a respiratory rate of 24 and an oxygen saturation of 94% on room air. 4. A client 12 hours after a hysterectomy complaining of nausea.
2. A client 3 days post right knee replacement complaining of right calf pain with movement. Assessment for possible DVT should be performed and reported to the physician immediately.
The nurse cares for clients on the medical/surgical unit. After receiving report, which of the following clients should the nurse see FIRST? 1. An elderly client 2 days postop after a total hip replacement who slipped out of bed when trying to stand. 2. An elderly client with a history of cardiomyopathy who aspirated cooked cereal at breakfast. 3. An elderly client diagnosed with a right-sided CVA who requires assistance going to the bathroom. 4. An elderly client diagnosed with heart failure (HF) who has been vomiting for 3 days.
2. An elderly client with a history of cardiomyopathy who aspirated cooked cereal at breakfast. Ensure that client has patent airway; at risk to develop pneumonia.
The RN is leading a team of an NA and an LPN in the care of a group of clients. Which tasks should the nurse assign to the NA and LPN? 1. NA to perform two simple dressing changes; LPN to assess and care for two non-complex clients 2. NA to empty and record urinary catheter bag drainage; LPN to administer oral and IM medications 3. NA to assist clients with hygiene; LPN to provide postmortem care and meet with a deceased client's family 4. NA to take and document vital signs on all clients; LPN to complete the discharge paperwork to be reviewed with two clients
2. The scope of practice for the NA includes measuring and recording I&O and for the LPN includes administering oral and IM medications
The nurse learns that patients from a motor vehicle accident are being transferred to the emergency department (ED). The nurse performs triage in the ED. Which of the following patients should the nurse see FIRST? 1. A patient with ecchymosis and lacerations to the facial area. 2. A patient complaining of shortness of breath and pressure in the chest. 3. A patient with blood pressure of 90/60 and apical pulse of 120 bpm. 4. A patient complaining of dizziness and nervousness.
3. A patient with blood pressure of 90/60 and apical pulse of 120 bpm. Vital signs indicate shock; most unstable patient.
After exposure to hot weather and sun, clients with signs and symptoms of heat-related ailment rush to the Emergency Department (ED). Sort clients into those who need critical attention and those with less serious conditions. 1. An elderly traffic enforcer who complains of dizziness and syncope after standing under the heat of the sun for several hours to perform his job. 2. A comparatively healthy housewife who states that the air conditioner has been down for 5 days and who exhibits hypotension, tachypnea, profuse diaphoresis, and fatigue. 3. A sportsman who complains of severe leg cramps and nausea, and displays paleness, tachycardia, weakness, and diaphoresis. 4. An abandoned person who is a teacher; has altered mental state, weak muscle movement, hot, dry, pale skin; and whose duration of heat exposure is unknown.
4, 1, 3, 2 4. The abandoned person has symptoms of heat stroke, a medical emergency, which heightens the risk of brain damage. The sequelae of the insult may persist beyond the initial CNS dysfunction, involving injury to the gut, kidney, skeletal muscle, or other organ systems. 1. The elderly traffic enforcer is at risk for heat syncope and should be instructed to relax in a cool environment and withdraw from approaching related circumstances. It represents a temporary, self-limited dizziness, weakness, or loss of consciousness during prolonged standing or positional changes in a hot environment, including physical activity. 3. The sportsman is experiencing heat cramps, which can be treated with rest and fluids. This condition is due to a relative deficiency of sodium, potassium, chloride, or magnesium. Other symptoms may include nausea, vomiting, fatigue, weakness, sweating, and tachycardia. 2. The homemaker is having heat exhaustion and management includes IV or oral fluids and settling in a cool area. External temperatures may be more moderate if associated with intense physical exertion. Survey-based data has shown that some of the most common symptoms are headache, exhaustion, or a combination of symptoms.
The nurse coming on duty receives the report from the nurse going off duty. Which of the following clients should the on-duty nurse assess first? 1. The 58-year-old client who was admitted 2 days ago with heart failure, BP of 126/76, and a respiratory rate of 21 breaths a minute. 2. The 88-year-old client with end-stage right-sided heart failure, BP of 78/50, and a DNR order. 3. The 62-year-old client who was admitted one day ago with thrombophlebitis and receiving IV heparin. 4. A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving IV diltiazem (Cardizem).
4. A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving IV diltiazem (Cardizem). The client with A-fib has the greatest potential to become unstable and is on IV medication that requires close monitoring. After assessing this client, the nurse should assess the client with thrombophlebitis who is receiving a heparin infusion, and then go to the 58-year-old client admitted 2-days ago with heart failure (her s/s are resolving and don't require immediate attention). The lowest priority is the 89-year-old with end stage right-sided heart failure, who requires time consuming supportive measures.
Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first? A. A client with diabetes being discharged today. B. A 35-year-old male with tracheostomy and copious secretions. C. A teenager scheduled for physical therapy this morning. D. A 78-year-old female client with a pressure ulcer that needs dressing change.
B. A 35-year-old male with tracheostomy and copious secretions. The patient with an airway problem should be given the highest priority. The ABCs identifies the airway, breathing and cardiovascular status of the patient as the highest of all priorities in that sequential order. Option A: The client who was discharged today is not a priority because he is stable enough to be sent home. Maslow's Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others and the self-actualization needs in that order of priority. Option C: The teenager who will undergo physical therapy is under Maslow's safety and physiological needs. The psychological or emotional, safety, and security needs include needs like low level stress and anxiety, emotional support, comfort, environmental and medical safety and emotional and physical security. Option D: The client needing a dressing change for her pressure ulcer belongs to Maslow's physical and biological needs. Some physical needs include the need for the ABCs of airway, breathing and cardiovascular function, nutrition, sleep, fluids, hygiene and elimination.
Nurse Skye is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first? A. A client scheduled for cardiac ultrasound this morning. B. A client with syncope being discharged today. C. A client with chronic bronchitis on nasal oxygen. D. A client with diabetic foot ulcer that needs a dressing change.
C. A client with chronic bronchitis on nasal oxygen. A client with airway problems should be attended first. When the nurse needs to prioritize patients, Maslow's hierarchy of needs theory is used to decide which patient is to be seen first. A part of Maslow's hierarchy of needs is airway, breathing, and circulation (ABC),which are physiological elements that are needed for the body to survive and help determine one's level of health. Observing ABCs is a rapid assessment of life-threatening conditions in order of priority. Option A: Clinical judgment and prioritization of patient care is built on the nursing process. Nurses learn the steps of the nursing process in their foundational nursing course and utilize it throughout their academic and clinical career to direct patient care and determine priorities. Analysis (interpreting what is going on with the patient through reviewing lab work, diagnostic testing, patient history, complaints and observations) comes after assessment. Option B: The client who was discharged today is not a priority because he is stable enough to be sent home. Maslow's Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others and the self-actualization needs in that order of priority. Option D: The client needing a dressing change for her pressure ulcer belongs to Maslow's physical and biological needs. Some physical needs include the need for the ABCs of airway, breathing and cardiovascular function, nutrition, sleep, fluids, hygiene and elimination.
You are acting as a preceptor for a newly graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide care to which patients? Select all that apply. A. A 38-year old with moderate persistent asthma awaiting discharge. B. A 63-year old with a tracheostomy needing tracheostomy care every shift. C. A 56-year old with lung cancer who has just undergone left lower lobectomy. D. A 49-year old just admitted with a new diagnosis of esophageal cancer.
A, B Option A: A patient who is waiting for discharge may be stable enough for the care of the student nurse. The client is the center of care. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs. Option B: The new RN is at an early point in her orientation. The most appropriate patients to assign to her are those in stable condition who require routine care. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the policies and procedures within the particular healthcare facility. Option C: The patient with the lobectomy will require the care of a more experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. Some needs require high levels of professional judgment and skill; and other patient needs are somewhat routine and without the need for high levels of professional judgment and skill. Option D: The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. As the new nurse advances through her orientation, you will want to work with her in providing care for these patients with more complex needs.
The charge nurse on the cardiac unit is planning assignments for the day. Which of the following is the most appropriate assignment for the float nurse that has been reassigned from labor and delivery? A. A one-week postoperative coronary bypass patient, who is being evaluated for placement of a pacemaker prior to discharge. B. A suspected myocardial infarction patient on telemetry, just admitted from the Emergency Department and scheduled for an angiogram. C. A patient with unstable angina being closely monitored for pain and medication titration. D. A post-operative valve replacement patient who was recently admitted to the unit because all surgical beds were filled.
A. A one-week postoperative coronary bypass patient, who is being evaluated for placement of a pacemaker prior to discharge. The charge nurse planning assignments must consider the skills of the staff and the needs of the patients. The labor and delivery nurse who is not experienced with the needs of cardiac patients should be assigned to those with the least acute needs. The patient who is one-week post-operative and nearing discharge is likely to require routine care. A new patient admitted with suspected MI and scheduled for angiography would require continuous assessment as well as coordination of care that is best carried out by experienced staff. The unstable patient requires staff that can immediately identify symptoms and respond appropriately. A post-operative patient also requires close monitoring and cardiac experience.
Nurse Jenny of Nurseslabs Medical Center is planning care for a client who had undergone colposcopy. Which of the following actions should the RN take first? A. Discuss the client's fear regarding potential cervical cancer. B. Assist with silver nitrate application to the cervix to control bleeding. C. Give instructions regarding douching and sexual relations. D. Administer pain medications.
B. Assist with silver nitrate application to the cervix to control bleeding. Colposcopy is a procedure to examine the cervix, vagina, and vulva for signs of disease. The priority nursing action when caring for a client who underwent colposcopy is to assist in controlling potential bleeding by applying silver nitrate to the cervix. Option A: Colposcopy is a procedure in which a lighted, magnifying instrument called a colposcope is used to examine the cervix, vagina, and vulva. The indications for a colposcopy to be performed are risk-based. Women referred for colposcopy have a variety of underlying risks for cervical pre-cancer based on their cytological results, the HPV testing if it was performed, and personal history of cervical dysplasia. Option C: There is no required preparation for the patient having the colposcopy; however, it can be difficult to perform if she is on her menstrual cycle due to obscuring blood. Having the room with the proper equipment readily available will expedite the patient's visit. Option D: The procedure is typically not painful. It does not require local or regional anesthesia. Slight discomfort may be felt when a speculum is inserted into the vagina, which can be minimized by deep breathing during the procedure.
Sally is a nurse working in an emergency department and receives a client after a radiological accident. Which task is the utmost priority for the nurse to do first? A. Decontaminate the client's clothing. B. Decontaminate the open wound on the client's thigh. C. Decontaminate the examination room the client is placed in. D. Save the client's vomitus for analysis by the radiation safety staff.
B. Decontaminate the open wound on the client's thigh. Decontaminating an open wound is the first priority for the client. This minimizes the absorption of radiation in the client's body. A radiological accident is an event that involves the release of potentially dangerous radioactive materials into the environment. This release is usually in the form of a cloud or "plume" and could affect the health and safety of anyone in its path. Option A: Getting radioactive material off the body as soon as possible can lower a worker's radiation dose from external contamination. Removing outer clothing and showering or, at a minimum, washing the face, hands, and any other exposed skin are essential decontamination steps. Option C: Decontamination of emergency response workers, their clothing, and any equipment, including PPE they may be using, is essential to limit radiation dose and prevent the spread of radioactive contamination outside of the response area. Option D: A prodromal period during which victims may experience loss of appetite, nausea, vomiting, fatigue, and diarrhea; after extremely high doses, additional symptoms such as fever, prostration (laying down), respiratory distress, and hyper-excitability can occur. In cases where the dose is not sufficient to cause rapid death, these symptoms usually disappear within 1-2 days.
Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first? A. Call for help to get the client back in bed B. Establish whether the client is responsive C. Assist the client back to bed D. Ask the client what happened
B. Establish whether the client is responsive Assess the client's current level of consciousness first to determine whether the patient has had a loss of consciousness then do the remaining choices if possible. The initial step is to evaluate for reactivity using objective measures. Address the patient verbally, progress to light shaking, then progress to more intense mechanical stimulation. Option A: After establishing the client's ABCs, the nurse may call for help. The initial step in the evaluation of an unconscious patient is to evaluate for the basic signs of life. The American Heart Association recommends examining for a pulse, followed by assessing airway patency and breathing pattern. Option C: If the client is stable and has been seen by a physician, the nurse may assist him back to his bed. The best practice for reporting level of responsiveness is to document specifically how the patient reacted to the external stimulus provided for testing. Option D: History regarding an unconscious patient is based on supplementary data. Questioning a person who has good knowledge of the recent history of the patient is preferable. The physical exam should be repeated at least daily, in a sequential fashion, and documented systematically.
After a change of shift, you are assigned to care for the following patients. Which patient should you assess first? A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab. B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation. C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics. D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator.
D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator. The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. In particular, a patient who is chronically on short-acting beta-2 agonists risks not achieving the same relief from their medicine as they once did. This phenomenon is called receptor downregulation. It happens because a portion of the receptors targeted end up being inactivated by the body due to overuse. Option A: The sterile sputum specimen of the patient should be sent to the laboratory for not more than 60 minutes, or it will not be acceptable. This is not an urgent case and can be done after the nurse sees the other patients. Option B: In COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable. In the treatment of exacerbations of chronic obstructive pulmonary disease (COPD), oxygen should be titrated to achieve a target oxygen saturation range of 88-92%. This results in a greater than twofold reduction in mortality, compared with the routine administration of high-concentration oxygen therapy Option C: The other patients need to be assessed as soon as possible, but none of their situations are urgent. Patients older than 60 years or younger than 4 years of age have a relatively poorer prognosis than young adults. If pneumonia is left untreated, the overall mortality may become 30%. The Pneumonia Severity Index (PSI) may be utilized as a tool to establish a patient's risk of mortality.
Jenna is a nurse from the medical-surgical unit of a tertiary hospital. She was asked to float on the orthopedic in which she has no prior experience working on. Which client should be assigned to her? A. A client with a cast for a fractured femur and who has numbness and discoloration of the toes. B. A client with balanced skeletal traction and needs assistance with morning care. C. A client who had an above-the-knee amputation yesterday and currently has a temperature of 101.4ºF. D. A client who had a total hip replacement two days ago and needs blood glucose monitoring.
D. A client who had a total hip replacement two days ago and needs blood glucose monitoring. A nurse from the medical-surgical floor floated to the orthopedic unit should be given clients with a stable condition as those who have care similar to her training and experience. A client who is in a postoperative state is more likely to be in a stable condition. Option A: The client may be experiencing compartment syndrome and would need the expertise of an orthopedic nurse. Acute compartment syndrome is a condition in which there is increased pressure within a closed osteofascial compartment, resulting in impaired local circulation. Without prompt treatment, acute compartment syndrome can lead to ischemia and eventually, necrosis. Option B: The care of a patient with skeletal traction would need a nurse who had experience with handling the apparatus. It requires frequent reassessment of neurovascular function of the extremity after application of the traction. Option C: A newly recovered postoperative patient should be monitored by an experienced ortho nurse. An above-knee amputation is associated with enormous morbidity; unlike a below-knee amputation, fitting a prosthesis for an above-knee stump is difficult.
