Delegation

4

A client has severe pain and bladder distention related to urinary retention and possible obstruction. An experienced UAP states that she received training in Foley catheter insertion at a previous job. What task can be delegated to this UAP? 1. Assessing the bladder distention and the pain associated with urinary retention 2. Inserting the Foley catheter, once you ascertain that she knows sterile technique 3. Evaluating the relief of pain and bladder distention after the catheter is inserted 4. Measuring the urine output after the catheter is inserted and obtaining a urine specimen

1

A client with lung cancer has received oxycodone (Roxicodone) 10 mg orally for pain. When the student nurse assesses the client, which finding would you instruct the student to report immediately? 1. Respiratory rate of 8 to 10 breaths/min 2. Decrease in pain level from 6 to 2 (on a scale of 10) 3. Request by the client that the room door be closed 4. Heart rate of 90 to 100 beats/min

1

A client's potassium level is 6.7 mEq/L. Which intervention should you delegate to the first-year student nurse whom you are supervising? 1. Administer sodium polystyrene sulfonate (Kayexalate) 15 g orally. 2. Administer spironolactone (Aldactone) 25 mg orally. 3. Assess the electrocardiogram (ECG) strip for tall T waves. 4. Administer potassium 10 mEq orally.

1

A hospitalized patient with AIDS has a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements related to nausea and anorexia. Which nursing action is most appropriate to delegate to an LPN/LVN who is providing care to this patient? 1. Administering oxandrolone (Oxandrin) 5 mg daily 2. Assessing the patient for other nutritional risk factors 3. Developing a plan of care to improve the patient's appetite 4. Providing instructions about a high-calorie, high-protein diet

2

A primary nursing responsibility is the prevention of lung cancer by assisting patients in cessation of smoking or other tobacco use. Which task would be appropriate to delegate to an LPN/LVN? 1. Development of a "quit plan" 2. Explanation of how to apply a nicotine patch 3. Discussion of strategies to avoid relapse

1

As the nurse manager in a public health department, you are implementing a plan to reduce the incidence of infection with human immunodeficiency virus (HIV) in the community. Which nursing action will you delegate to health assistants working for the agency? 1. Supplying injection drug users with sterile injection equipment such as needles and syringes 2. Interviewing patients about behaviors that indicate a need for annual HIV testing 3. Teaching high-risk community members about the use of condoms in preventing HIV infection 4. Assessing the community to determine which population groups to target for education

3

For a patient who is experiencing side effects of radiation therapy, which task would be the most appropriate to delegate to the UAP? 1. Helping the patient to identify patterns of fatigue 2. Recommending participation in a walking program 3. Reporting the amount and type of food consumed from the tray 4. Checking the skin for redness and irritation after the treatment

3

For care of a patient who has oral cancer, which task would be appropriate to delegate to an LPN/LVN? 1. Assisting the patient to brush and floss 2. Explaining when brushing and flossing are contraindicated 3. Giving antacids and sucralfate suspension as ordered 4. Recommending saliva substitutes

2

For client education about nonpharmaceutical alternatives, which topic could you delegate to an experienced LPN/LVN, who will function with your continued support and supervision? 1. Therapeutic touch 2. Application of heat and cold 3. Meditation 4. Transcutaneous electrical nerve stimulation (TENS)

1,2,4,6

In the care of a patient with neutropenia, what tasks can be delegated to a UAP? (Select all that apply.) 1. Taking vital signs every 4 hours 2. Reporting temperature of more than 100.4° F (38° C) 3. Assessing for sore throat, cough, or burning with urination 4. Gathering the supplies to prepare the room for protective isolation 5. Reporting superinfections, such as candidiasis 6. Practicing good hand-washing technique

1

In the care of clients with pain and discomfort, which task is most appropriate to delegate to the UAP? 1. Assisting the client with preparation of a sitz bath 2. Monitoring the client for signs of discomfort while ambulating 3. Coaching the client to deep breathe during painful procedures 4. Evaluating relief after applying a cold compress

3

The UAP asks you why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is your best response? 1. "The client's low phosphorus is probably due to malnutrition." 2. "The client is just worn out from not getting enough rest." 3. "The client's skeletal muscles are weak because of the low phosphorus." 4. "The client will do more for himself when his phosphorus level is normal."

1

The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to you, a newly-graduated RN. Which action can you delegate to the UAP? 1. Providing oral care every 3 to 4 hours 2. Monitoring for indications of dehydration 3. Administering 0.45% saline by IV line 4. Assessing daily weights for trends

2

The client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a UAP? 1. Administering IV fluids as prescribed by the physician 2. Providing straws and offering fluids between meals 3. Developing a plan for added fluid intake over 24 hours 4. Teaching family members to assist the client with fluid intake

1,2,3,4

The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? (Select all that apply.) 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 3. Observing the lips, tongue, and mucous membranes 4. Providing mouth care every 2 hours while the client is awake 5. Seeking a dietary consult to increase fluids on meal trays

4

The team is providing emergency care to a client who received an excessive dose of narcotic pain medication. Which task is best to delegate to the LPN/LVN? 1. Calling the physician and reporting the situation using the SBAR (situation, background, assessment, recommendation) format 2. Giving the ordered dose of Narcan and evaluating the response to therapy 3. Monitoring the respiratory status for the first 30 minutes 4. Applying oxygen per nasal cannula as ordered

2

When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be the most appropriate to assign to an LPN/LVN under the supervision of a team leader RN? 1. A patient with severe anemia secondary to GI bleeding 2. A patient who needs enemas and antibiotics to control GI bacteria 3. A patient who needs preoperative teaching for bowel resection surgery 4. A patient who needs central line insertion for chemotherapy

2,3

Which action should you delegate to a UAP for the client with diabetic ketoacidosis? (Select all that apply.) 1. Checking fingerstick glucose results every hour 2. Recording intake and output every hour 3. Measuring vital signs every 15 minutes 4. Assessing for indicators of fluid imbalance 5. Notifying the provider of changes in glucose level

2,5,6

Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? (Select all that apply.) 1. Anxious client with chronic pain who frequently uses the call button 2. Client on the second postoperative day who needs pain medication before dressing changes 3. Client with human immunodeficiency virus (HIV) infection who reports headache and abdominal and pleuritic chest pain 4. Client with chronic pain who is to be discharged with a new surgically-implanted catheter 5. Client who is reporting pain at the site of a peripheral IV line 6. Client with a kidney stone who needs frequent PRN pain medication

2,3,6

Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader? (Select all that apply.) 1. Client who needs preoperative teaching for the use of a PCA pump 2. Client with a leg cast who needs neurologic and circulatory checks and PRN hydrocodone 3. Client who underwent a toe amputation and has diabetic neuropathic pain 4. Client with terminal cancer and severe pain who is refusing medication 5. Client who reports abdominal pain after being kicked, punched, and beaten 6. Client with arthritis who needs scheduled pain medications and heat applications

1,3,5,6

Which clients must be assigned to an experienced RN? (Select all that apply.) 1. Client who was in an automobile crash and sustained multiple injuries 2. Client with chronic back pain related to a workplace injury 3. Client who has returned from surgery and has a chest tube in place 4. Client with abdominal cramps related to food poisoning 5. Client with a severe headache of unknown origin 6. Client with chest pain who has a history of arteriosclerosis

1

You are caring for a patient with esophageal cancer. Which task could be delegated to a UAP? 1. Assisting the patient with oral hygiene 2. Observing the patient's response to feedings 3. Facilitating expression of grief or anxiety 4. Initiating daily weighings

2

You are working in an AIDS hospice facility that is also staffed with LPNs/LVNs and UAPs. Which nursing action will you delegate to the LPN/LVN you are supervising? 1. Assessing patients' nutritional needs and individualizing diet plans to improve nutrition 2. Collecting data about the patients' responses to medications used for pain and anorexia 3. Teaching the UAPs about how to lower the risk for spreading infections 4. Assisting patients with personal hygiene and other activities of daily living as needed

3

for care of a patient who has oral cancer, which task would be appropriate to delegate to an LPN/LVN? 1. Assisting the patient to brush and floss 2. Explaining when brushing and flossing are contraindicated 3. Giving antacids and sucralfate suspension as ordered 4. Recommending saliva substitutes