Decision Making, Problem Solving, Time Management, Priority Setting
The 5 Rights of Delegation
1. right task: the take is within the delegate's scope of practice 2. right person: the person is competent to perform the task 3. right communication: the nurse gives the right direction to complete the task 4. right feedback: the nurse works collaboratively with the delegate 5. right follow-up: the nurse follow-up on the task after it has been completed
The elderly wife of a client with a total hip replacement who is being discharged home tells the nurse "I am really worried about taking my husband home. I don't know how I will be able to take care of him." Which response would be the most appropriate for the rehabilitation nurse? A. "We can arrange for a home health nurse to come visit your husband." B. "Have you thought about placing your husband in a nursing home?" C. "I will ask your husband's HCP to come talk to you about your concerns." D. "I can see that you are worried but I am sure that everything will be all right."
Correct answer: A According the NCSBN, management of care includes being knowledgeable about referrals. This client would benefit from a home health-care nurse to evaluate the client's home and the wife's ability to care for the client. The nurse should help the client care for husband in the home. Placing him in a nursing home may be a possibility if she is unable to care for him, but the most appropriate response would be trying to help the wife care for her husband in the home. The HCP can talk with the wife but will not be able to address her concerns of taking care of her husband when he is discharged home. Saying "everything will be all right" is false reassurance and doesn't address the wife's concern about being able to care for her husband.
The emergency department nurse is assessing a female client who has a laceration on the forehead and a black eye. The nurse asks the man who is with the client to please leave the room. The man refuses to leave the room. Which action should the nurse take first? A. Tell the man the client needs to go to the x-ray department B. Notify hospital security and have the man removed from the room C. Explain that the man must leave the room while the nurse checks the client D. Give the client a brochure with information about a women's shelter
Correct answer: A The nurse needs to remove the man from the room so that the nurse can talk to the client and discuss probable abuse. Taking the client to the x-ray department may not rouse suspicion in the man and may allow the client to discuss the situation. B. This may be needed but it is not the first intervention. This action may cause the man to get angrier in the emergency department, or it may cause more problems for the woman if she goes home with him C. This nurse could demand the man leave the room, but this action may cause the man's anger to escalate; therefore, the first intervention is to remove the client from the room. D. The nurse shouldn't allow the man to see his discussing a woman's shelter with the client or providing a client with a brochure. This could further anger the man, especially if the woman goes home with him
The female UAP tells the nurse she has helped 1 day postpartum client change her peri-pad 3 times in the last 4 hours. Which action should the nurse implement? A. Ask the UAP why the nurse was not notified earlier B. Go to the room and check the client immediately C. Instruct the UAP to massage the client's uterus D. Document the finding in the client's chart
Correct answer: B This client may or may not be experiencing excessive bleeding, but the nurse's first intervention is to assess the client. Any time the nurse receives information from another staff member about a client who may be experiencing a complication, the nurse must assess the client first. The nurse should not make decisions about clients' needs based on another staff member's information.
A client is being prepared for a bronchoscopy. Which of the following preoperative activities would be appropriate for the nurse to delegate to the nursing assistant? A. Obtaining the signed consent form B. Placing the client on NPO status C. Instructing the client about the procedure D. Evaluating the client's level of anxiety
Correct answer: B It would be appropriate for the nurse to instruct the assistant to place the client on NPO status. It is the responsibility of the physician performing the procedure to obtain the client's informed consent and have the form signed. It is the responsibility of the registered nurse to teach clients and evaluate their health status. These responsibilities cannot be delegated to nursing assistants.
Which task should a nurse choose to delegate to a nursing assistant? Select all that apply. A. Assessing a client's pain B. Taking a client's vital signs C. Documenting a client's oral intake D. Performing a blood glucose check E. Evaluating a response to a client's blood pressure medication
Correct answer: B, C, D Registered nurses are resonsible for all phases of the nursing process. These responsibilities include assessing a client's pain and evaluating a client's response to treatment. A nurse may delegate tasks such as taking vital signs, documenting intake and output, and performing blood glucose checks if she follows the five rights of delegation.
The nurse is completing the admission assessment on the client scheduled for cystectomy with creation of an ileal conduit. The client tells the nurse "I am taking saw palmetto for my enlarged prostate." Which action should the nurse implement first? A. Notify the client's HCP to write an order for the herbal supplement B. Ask the client why he is taking an herb for his enlarged prostate C. Consult with the pharmacist to determine any potential drug interaction D. Look up saw palmetto in the Physician's Desk reference
Correct answer: C According to the NSCBN NCLEX-RN test plan, collaboration with interdisciplinary team members is part of the management of care. The nurse should first consult with the pharmacist to determine whether the client is taking any medications that could interact with saw palmetto. If the HCP deems that the client can continue to take the herbal supplement, then an order must be written; however, this is not the first intervention. The nurse could ask for clarification of why he is taking the herbal supplement, but this is not the first intervention. Many clients use herbal supplements for a variety of health-care needs. The PDR is available to research medications, not herbal supplements.
A float nurse is assigned to a surgical unit. The nurse is receiving 2 clients from the post-anesthesia care unit (PACU) at the same time. When delegating tasks to other PACU personnel who are not known to the nurse, which question would be most important to ask? A. What is your highest educational level? B. How long have you worked on this floor? C. Are you comfortable in performing the tasks being assigned? D. Who provided you the unit training?
Correct answer: C Since the float nurse is not familiar with staff, it is important to ask the worker if s/he is comfortable and had instruction in the task assigned. Principles of delegation state that the right task in the right situation by the right personnel is essential to client care. Asking the highest educational level, how long they worked on the floor, and who provided their training is not as important as if they are comfortable with performing the task.
Which task may be safely delegated to a licensed practical nurse (LPN)? A. Teaching a client newly diagnosed with diabetes mellitus about insulin administration. B. Admitting a client who was admitted with a thoracotomy to the nursing unit from the PACU C. Changing the dressing of a client who underwent surgery two days ago D. Administering an IV bolus of morphine sulfate to a client experiencing pain
Correct answer: C The registered nurse may safely delegate dressing changes for the client who underwent surgery 2 days ago to the LPN. Teaching a client newly diagnosed with diabetes mellitus about insulin administration requires careful evaluation of the effectiveness of teaching and may not be delegated to an LPN. Admitting a client to the PACU is beyond the scope of practice for an LPN; LPNs aren't permitted to give IV push drugs.
The wife of a client diagnosed as terminal is concerned that the client is not eating or drinking. Which is the nurse's best response? A. "I will start an IV if your husband continues to refuse to eat or drink." B. "You should discuss placing a PEG feeding tube in your husband with the HCP." C. "This is normal at the end of life; the dehydration produces a sense of euphoria." D. "You are right to be concerned. Would you like to talk about your worry?"
Correct answer: C Refusal to take in foods and liquids produces a natural euphoria and makes the dying process easier on the client. This is an appropriate teaching statement. A. The body naturally begins to slow down, and clients may not wish to take in liquids or nourishment. This can produce a natural euphoria and make the dying process easier on the client. IV fluids would interfere with this process and would increase secretions that the client cannot handle, thus making the client more uncomfortable. B. A PEG feeding tube would increase the intake of the client and would increase secretions that the client cannot handle. This can require suctioning the client and further augmenting the client's discomfort. D. This is a therapeutic response, but factual information is needed by the wife to accept the process.
The nurse on the medical unit is preparing to administer 0900 medications. Which medication should the nurse administer first? A. The mucosal barrier agent, sucralfate (Carafate), to a client who has GERD B. The proton-pump inhibitor, pantoprazole (Protonix), to a client with an ulcer C. The Humulin N insulin to a client who is no longer NPO for an x-ray D. The steroid, prednisone, to a client with asthmatic bronchitis
Correct answer: C The client who is no longer NPO should receive the long-acting insulin as soon as possible. This medication should be administered first. A mucosal barrier agent must be administered on an empty stomach for the best results. The nurse would question administering this medication 1 to 1 1/2 hours after breakfast. The proton-pump inhibitor can be administered within the 30-minute leeway before or after the scheduled administration time. The steroid medication can be administered within the 30-minute leeway before and after administration time.
The client who is 2 days post-operative for a left pneumonectomy has an apical pulse of 128 and a blood pressure of 80/50. Which intervention should the nurse implement first? A. Notify the HCP immediately B. Assess the client's incisional wound C. Prepare to administer dopamine, a vasopressor D. Increase the client's IV rate
Correct answer: D Increasing the IV rate with provide the client with circulatory volume immediately. Therefore, this is the first intervention. A. The HCP should be notified, but this is not the first intervention. The HCP will require other information, such as what the incision looks like and whether there is any bleeding that can be seen, before making any decisions. The nurse, therefore, should first provide emergency care to the client - in this case, support the client's circulatory system by increasing the IV rate - and then assess the patient before reporting to the HCP. B. The incisional wound should be assessed, but the priority is maintaining circulatory status because the patient's vital signs indicate shock. C. The client may require medication, such as dopamine, to increase BP, but the client's circulatory system needs immediate support, which increasing the IV rate will provide.
The primary nurse overhears the UAP telling a family member of a client, "One of the clients at the rehabilitation until will be going to prison because he was charged with vehicular manslaughter because 2 people died after he hit them driving drunk." Which action should the primary nurse implement first? A. Apologize to the family member for the UAP's comments B. Tell the UAP that the comment is a violation of HIPPA C. Allow the UAP to complete the conversation then discuss the situation D. Interrupt the conversation and tell the UAP to go to the nurse's station
Correct answer: D The nurse should stop the conversation immediately, and asking the UAP to go to the nurse's station doesn't embarrass the UAP. This is a violation of HIPPA and is gossiping about another client on the unit.
The nurse is caring for an elderly client with a possible diagnosis of pneumonia who has just been admitted to the hospital. The client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to the nursing assistant? Select all that apply. A. Obtaining vital signs B. Initiating oxygen therapy as needed C. Applying anti-embolic stockings D. Assessing the client's breath sounds E. Keeping the client oriented
Correct answers: A, C, E It is appropriate for the nurse to delegate obtaining vital signs and applying anti-embolic stockings to the nursing assistant. The nursing assistant can also help keeping the client oriented to time, person, and place by talking with the client. The registered nurse is responsible for evaluating the quality and character of the client's vital signs, but the assistant may take the vital signs and report readings to the nurse. It is the registered nurse's responsibility to assess the client's need for oxygen therapy and apply as needed in accordance with physician's orders. It is also the registered nurse's responsibility to perform the nursing history and assess the client's breath sounds.
