Nclex priority and delegation

The nurse is making assignments for the next shift. Which client can be assigned to a licensed practical nurse/licensed vocational nurse (LPN/LVN)? Select all that apply.

A client who needs assistance with colostomy irrigation A client who is receiving glargine subcutaneously. An LPN/LVN can perform colostomy irrigation and administer subcutaneous injections. A client who just had CABG is unstable and needs to be monitored by an RN. The initial admission assessment should also be performed by an RN. C3 to C5 injury may cause respiratory compromise. Possible paralysis of diaphragm due to phrenic nerve involvement may occur. This client is unstable and should be assigned to an RN.

A nurse's initial client assessment indicates probable opioid overdose complicated by alcohol ingestion. What intervention should the nurse perform first?

Administer IV naloxone. If a client has ingested opioids, naloxone would reverse the effects and rouse the client. Intravenous fluids would most likely be administered, and this client would be closely monitored over a period of several hours to several days. The client should be screened for drugs, but results may not come back for several hours.

A nurse suspects a client is experiencing alcohol withdrawal syndrome. What is the nurse's priority action?

Ask the client about his drinking. Confirming suspicions directly with the client is the most reliable way to diagnosis and treat withdrawal symptoms. If the client isn't cooperative, verification can be sought from the family. Social services aren't required at this time, but may be helpful in discharge planning. Giving false reassurance isn't therapeutic for the client.

After undergoing a cardiac catheterization, a client has a large puddle of blood under his buttocks. What is the nurse's priority action?

Assess the groin. 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.

The nurse is caring for a client with type 1 diabetes mellitus. At 0300, the nurse finds the client disoriented to time and place, diaphoretic, and reports palpitations. What is the nurse's priority intervention?

Check blood glucose level. If the client is hypoglycemic, administration of a simple carbohydrate is appropriate. If the client is conscious, the carbohydrate may be given orally. If consciousness is altered, subcutaneous or intramuscular glucagon is appropriate. This client is showing symptoms of hypoglycemia, additional insulin would further lower the blood glucose.

The nurse is planning care for an infant with bronchiolitis who requires monitoring for fluid balance. What is the most accurate assessment the nurse can perform to determine the total body water volume of the infant?

Daily weight. The most accurate clinical assessment for total body water is weight. Weight helps assess all the water in all spaces while other assessments are dependent on renal function or movement of fluid between spaces, making them less accurate. While sodium levels are relevant, they cannot inform about total body water volume; an infant can be in fluid volume deficit and hyponatremic concurrently depending on how much sodium is lost in relation to water. Weighing diapers is a way of measuring output, but depending on the renal function of the infant, there can be very little urine output. The infant may be retaining fluids and actually be experiencing fluid volume excess or have very little urine output because of fluid volume deficit. Similarly, urine specific gravity can be altered by the kidney's ability to concentrate the urine, so it may not accurately reflect the total water volume.

A 76-year-old woman, with a history of osteoporosis is 24-hours postoperative for a total right hip replacement. What is the priority nursing action for this client?

Managing pain. Adequate pain relief will enable this client to engage in initial mobility exercises and prevent potential complications. Ambulating 50 feet is a longer-term goal. Wound care and nutrition are important post-surgical priorities to ensure wound healing, but are not the priority.

What is the nurse's priority action in caring for a client who has just had a liver biopsy?

Monitor vital signs. Internal bleeding is a potential complication following a liver biopsy. Elevated pulse and decreased blood pressure are indications that the client may be developing shock, which results in altered circulation. Physiologic needs take priority over psychological needs, Assessing feelings and teaching should be addressed after immediate needs. Pain is considered a psychological reaction unless the client is experiencing an acute episode that is causing physiologic response.

A nurse suspects an infant may have a tracheoesophageal fistula or esophageal atresia. What is the most important intervention by the nurse?

Report the suspicion to the healthcare provider. The provider needs to be told so that immediate diagnostic tests can be done to determine a definitive diagnosis with surgical correction. Oxygen should be given only after notifying the provider, except in an emergency. It is not the nurse's responsibility to inform the parents of the suspected finding. By the time tracheoesophageal fistula or esophageal atresia is suspected, the neonate would have already been placed in an isolette or a radiant warmer.

A 17-year-old primigravida with severe hypertension of pregnancy has been receiving magnesium sulfate I.V. for 3 hr. The latest assessment reveals deep tendon reflexes (DTR) of +1, flushing, blood pressure of 150/100 mm Hg, a pulse of 92 beats/min, a respiratory rate of 10 breaths/min, and urine output of 20 ml/hr. Which action would be most appropriate?

Stop the magnesium infusion. Magnesium sulfate should be withheld if the client's respiratory rate or urine output falls, or if reflexes are diminished or absent, all of which are true for this client. The client also shows other signs of impending toxicity, such as flushing and feeling warm. Inaction will not resolve the client's suppressed DTRs, low respiratory rate, and urine output. The client is already showing central nervous system depression because of excessive magnesium sulfate, so increasing the infusion rate is inappropriate. Impending toxicity indicates that the infusion should be stopped rather than just slowed down.