EAQ Prioritization (Week 3), Week 5 in Class delegation assignment, Week 2 Delegation quiz, EAQ Delegation Wk 2

Which action is the priority for a client who is admitted to the hospital with a severe head injury? 1 Maintain ventilation. 2 Prevent contractures. 3 Preserve skin integrity. 4 Monitor blood pressure.

1 Maintain ventilation.

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

1. Administer sodium polystyrene sulfonate 15 g orally.

The nurse is caring for a patient with esophageal cancer. Which task could be delegated to unlicensed assistive personnel (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 weights

1. Assisting the patient with oral hygiene

Which goal is a priority for a client who is unconscious after a cerebrovascular accident? 1 Promoting elimination 2 Maintaining the airway 3 Optimizing fluid volume 4 Preserving skin integrity

2 Maintaining the airway

Which complication is the nurse's main priority during the early postoperative period after a subtotal thyroidectomy? 1 Hemorrhage 2 Thyrotoxic crisis 3 Airway obstruction 4 Hypocalcemic tetany

3 Airway obstruction

The nurse is caring for a child who has an external fixation device on the leg. Which is the nurse's priority goal when providing pin care? 1 Easing pain 2 Minimizing scarring 3 Preventing infection 4 Preventing skin breakdown

3 Preventing infection

The team is providing emergency care to a client who received an excessive dose of opioid pain medication. Which task is best to assign to the LPN/LVN? A. Calling the health care provider (HCP) to report SBAR (situation, background, assessment, recommendation) B. Giving naloxone and evaluating response to therapy C. Monitoring the respiratory status for the first 30 minutes D. Applying oxygen per nasal cannula as ordered

D. Applying oxygen per nasal cannula as ordered

Which component of delegation is defined as "the ability to perform duties in a specific role"? a. Authority b. Supervision c. Responsibility d. Accountability

a. Authority

Which health care team member would the registered nurse (RN) state is accountable for establishing systems to communicate competency requirements related to delegation? a. RN b. Chief nursing officer (CNO) c. Licensed practical nurse (LPN) d. Unlicensed assistive personnel (UAP)

b. Chief nursing officer (CNO)

Which element creates an integrative process that fosters effective delegation decisions by the registered nurse (RN)? a. Ability b. Liability c. Stability d. Ethnicity

c. Stability

A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The client reports frequent nausea, pain that increases after meals, and black, tarry stools. The client recently joined Alcoholics Anonymous. The nurse would give priority to which client history item? 1 Black, tarry stools 2 Frequent nausea 3 Joining Alcoholics Anonymous 4 Pain that increases after meals

1 Black, tarry stools

After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client experiences a sudden onset of cyanosis, tachycardia, dyspnea, restlessness, and petechiae on the chest. Which is the priority nursing action? 1 Obtain vital signs. 2 Administer oxygen. 3 Notify the health care provider. 4 Auscultate the client's lung sounds.

2 Administer oxygen.

During a client's immediate postoperative period after a laryngectomy, which is a nursing priority? 1 Provide emotional support 2 Observe for signs of infection 3 Keep the trachea free of secretions 4 Promote a means of communication

3 Keep the trachea free of secretions

Which is the priority nursing intervention for a client admitted to the hospital with a brain attack (cerebrovascular accident)? 1 Changing position every 2 hours 2 Keeping a serial record of the pulse 3 Performing range-of-motion exercises 4 Monitoring for increased intracranial pressure

4 Monitoring for increased intracranial pressure

Which infection control activity should the charge nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Screening clients for upper respiratory tract symptoms 2. Asking clients about the use of immunosuppressant medications 3. Demonstrating correct hand washing to the clients' visitors 4. Disinfecting blood pressure cuffs after clients are discharged

4. Disinfecting blood pressure cuffs after clients are discharged

The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to a new-graduated RN. Which actions can the new-graduate RN delegate to the unlicensed assistive personnel (UAP)? Select all that apply A. Providing oral care every 3 to 4 hours B. Monitoring for indications of dehydration C. Administering 0.45% saline by IV line D. Record urine output when client voids E. Assessing daily weights for trends F. Help the client change position every 2 hours

A. Providing oral care every 3 to 4 hours D. Record urine output when client voids F. Help the client change position every 2 hours

You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced UAP? 1. Assessing the patient's respiratory status every 4 hours 2. Taking vital signs and pulse oximetry readings every 4 hours 3. Checking the ventilator settings to make sure they are as prescribed 4. Observing whether the patient's tube needs suctioning every 2 hours

Ans: 2 The UAP's educational preparation includes measuring vital signs, and an experienced UAP would know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN. Focus: Delegation, supervision; QSEN: TC; Concept: Collaboration

The nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin- resistant Staphylococcus aureus (VRSA). Which nursing action can be assigned to an LPN/LVN? A. Planning ways to improve the client's oral protein intake B. Teaching the client about home care of the leg ulcer C. Obtaining wound cultures during dressing changes D. Assessing the risk for further skin breakdown

C. Obtaining wound cultures during dressing changes

The nurse supervises an RN, LPN and nurse assistive personnel (NAP) on an acute care managed unit. The nurse should intervene if which is observed?

The LPN inspects and documents the condition of the sacral decubitus ulcer.

Which activities can registered nurses (RNs) engage in to develop delegation and supervisory strategies to adapt to their changing roles? Select all that apply. One, some, or all responses may be correct. a. Engaging the nurse mentor for guidance b. Practicing the nursing care process in various clinical settings c. Reinforcing delegation knowledge through continuing education d. Becoming familiar with the hierarchy of authority in the health care organization e. Seeking high-quality clinical delegation experience early in their careers

a. Engaging the nurse mentor for guidance c. Reinforcing delegation knowledge through continuing education e. Seeking high-quality clinical delegation experience early in their careers

Which statement is correct regarding delegation? Select all that apply. One, some, or all responses may be correct. a. It involves a transfer of authority. b. The delegator retains accountability for the outcome. c. The delegatee retains accountability for the outcome. d. It is the transfer of both responsibility and accountability. e. Principles of delegation outline what nurses need to know about the task.

a. It involves a transfer of authority. b. The delegator retains accountability for the outcome. e. Principles of delegation outline what nurses need to know about the task.

Which questions related to decision-making for delegation are appropriate according to the delegation right of "right circumstance"? Select all that apply. One, some, or all responses may be correct. a. Is the task legally appropriate to delegate? b. Is the prospective delegatee a willing and able employee? c. Are the equipment and resources available to complete the task? d. Does the delegatee have appropriate supervision to complete the task? e. Is the task appropriate to delegate based on the institutional policies and procedures?

c. Are the equipment and resources available to complete the task? d. Does the delegatee have appropriate supervision to complete the task?

Which activity performed by the licensed practical nurse (LPN) would be appropriate based on the principle of right task of delegation when caring for a client? a. Being willing to perform the task b. Providing feedback to the delegator c. Performing the task based on institutional policies d. Following appropriate supervision while performing the task

c. Performing the task based on institutional policies

As a part of the nursing curriculum, the nursing faculty is teaching nursing students about high-quality clinical delegation experiences and assigned the students to work with nursing mentors. Which skill would the nursing faculty expect the nursing students to develop via this approach? a. Proficiency in delegation b. Application of theory to delegation c. Professional self-confidence in delegation d. Development of clinical judgment in delegation

c. Professional self-confidence in delegation

When evaluating a task performed by a delegatee, the registered nurse (RN) finds that the delegatee fails to provide appropriate feedback. Which right of delegation is compromised in this situation? a. Right task b. Right person c. Right supervision d. Right communication

c. Right supervision

Which of the following rights of the "Five Rights of Delegation" would be considered the most important right of delegation? a. Right person b. Right supervision c. Right circumstance d. Right communication and direction

d. Right communication and direction

Which activity performed by the registered nurse (RN) indicates effective delegation? a. Following one-way communication with the delegatee b. Assigning a task to a newly licensed practical nurse (LPN) c. Providing feedback to the delegatee while performing the task d. Supervising and monitoring the licensed practical nurse (LPN) about the different activities

d. Supervising and monitoring the licensed practical nurse (LPN) about the different activities

You are the charge nurse. A client with chronic pain reports to you that the nurses have not been responding to requests for pain medication. What is your initial action? 1. Check the medication administration records (MARs) for the past several days. 2. Ask the nurse educator to provide in-service training about pain management. 3. Perform a complete pain assessment on the client and take a pain history. 4. Have a conference with the nurses responsible for the care of this client.

4. Have a conference with the nurses responsible for the care of this client.

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? A. A patient with severe anemia secondary to GI bleeding B. A patient who needs enemas and antibiotics to control GI bacteria C. A patient who needs preoperative teaching for bowel resection surgery D. A patient who needs central line insertion for chemotherapy

B. A patient who needs enemas and antibiotics to control GI bacteria

The client has fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to unlicensed assistive personnel (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

2. Providing straws and offering fluids between meals

The nurse manager in a public health department is implementing a plan to reduce the incidence of infection with human immunodeficiency virus (HIV) in the community. Which nursing action will be delegated to unlicensed assistive personnel (UAP) 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

1. Supplying injection drug users with sterile injection equipment such as needles and syringes

Which order of events would the nurse follow when performing a critical analysis using the nursing process as a guide for delegation? 1.Assessing the situation to determine what is legally appropriate to delegate 2. Planning an intervention 3.Determining whether the delegatee is competent to perform the task safely 4.Implementing the plan including an observation of the delegatee 5.Evaluating whether the delegation process was completed safely and effectively

1.Assessing the situation to determine what is legally appropriate to delegate 2. Planning an intervention 3.Determining whether the delegatee is competent to perform the task safely 4.Implementing the plan including an observation of the delegatee 5.Evaluating whether the delegation process was completed safely and effectively

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. Which is the priority nursing intervention? 1 Obtain chest x-ray film immediately. 2 Notify the primary health care provider. 3 Place client in a high-Fowler position. 4 Assess the client's oxygen saturation level.

3 Place client in a high-Fowler position.

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

4. Measuring the urine output after the catheter is inserted and obtaining a urine specimen

An experienced LPN/LVN, under the supervision of the team leader RN, is assigned to provide nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/LVN? Select all that apply. A. Auscultating breath sounds B. Administering medications via metered-dose inhaler (MDI) C. Completing in-depth admission assessment D. Checking oxygen saturation using pulse oximetry E. Developing the nursing care plan F. Evaluating the patient's technique for using MDIs

A. Auscultating breath sounds B. Administering medications via metered-dose inhaler (MDI) D. Checking oxygen saturation using pulse oximetry

The nurse is supervising an RN who floated from the medical- surgical unit to the emergency department. The float nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which directions would the supervising nurse clearly provide to the RN? Select all that apply. A. Position the patient supine and turned on his side. B. Apply direct lateral pressure to the nose for 5 minutes. C. Maintain standard body substance precautions. D. Apply ice or cool compresses to the nose. E. Instruct the patient not to blow the nose for several hours. F. Teach the patient to avoid vigorous nose blowing.

B. Apply direct lateral pressure to the nose for 5 minutes. C. Maintain standard body substance precautions. D. Apply ice or cool compresses to the nose. E. Instruct the patient not to blow the nose for several hours. Not sure about F?

The nurse is working in a hospice facility for patients with acquired immunodeficiency syndrome (AIDS). The facility is staffed with LPNs/LVNs and unlicensed assistive personnel (UAP). Which action will the nurse assign to the LPN/LVN? A. Assessing patients' nutritional needs and individualizing diet plans to improve nutrition B. Collecting data about the patients' responses to medications used for pain and anorexia C. Developing UAP training programs about how to lower the risk for spreading infections D. Assisting patients with personal hygiene and other activities of daily living as needed

B. Collecting data about the patients' responses to medications used for pain and anorexia

Which of the nurse's statements are true regarding delegation? Select all that apply. One, some, or all responses may be correct. a. Delegation is a complex process. b. Delegation involves a single individual to achieve goals. c. Delegation involves transfer of responsibility and accountability. d. Delegation improves client care outcomes when used effectively. e. Delegation includes delegatees who allocate a portion of work to others

a. Delegation is a complex process. d. Delegation improves client care outcomes when used effectively.

The charge nurse is reviewing the records of clients who were assigned to a newly graduated RN. The RN has correctly documented dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should the charge nurse take first? 1. Make a note in the nurse's file and continue to observe clinical performance. 2. Refer the new nurse to the in-service education department. 3. Quiz the nurse about knowledge of pain management and pharmacology. 4. Give praise for documenting dose and time and discuss documentation deficits.

4. Give praise for documenting dose and time and discuss documentation deficits.

The student nurse, under the supervision of an RN, is reviewing a client's arterial blood gas results and notes an acute increase in arterial partial pressure of carbon dioxide (Paco2) to 51 mm Hg compared with the previous results. Which statement by the student nurse indicates accurate understanding of acid- base balance for this client? A. "When the Paco2 is acutely elevated, the blood pH should be lower than normal." B. "This client should be taught to breathe and rebreathe in a paper bag." C. "An elevated Paco2 always means that a client has an acidosis." D. "When a client's Paco2 is increased, the respiratory rate should decrease to compensate."

A. "When the Paco2 is acutely elevated, the blood pH should be lower than normal."

The nurse is acting as preceptor for a newly-graduated RN during the second week of orientation. The nurse would assign and supervise the new RN to provide nursing care for which patients? Select all that apply. A. A 38-year-old patient with moderate persistent asthma awaiting discharge B. A 63-year-old patient with a tracheostomy needing tracheostomy care every shift C. A 56-year-old patient with lung cancer who has just undergone left lower lobectomy D. A 49-year-old patient just admitted with a new diagnosis of esophageal cancer E. A 76-year-old patient newly diagnosed with type 2 diabetes F. A 69-year-old patient with emphysema to be discharged tomorrow

A. A 38-year-old patient with moderate persistent asthma awaiting discharge B. A 63-year-old patient with a tracheostomy needing tracheostomy care every shift Not sure about F?

A client is admitted to the oncology unit for chemotherapy. To prevent an acid-base problem, which finding would the nurse instruct the unlicensed assistive personnel (UAP) to report? A. Repeated episodes of nausea and vomiting B. Reports of pain associated with exertion C. Failure to eat all the food on the breakfast tray D. Client hair loss during the morning bath

A. Repeated episodes of nausea and vomiting

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

Ans: 1 The UAP is able to assist the client with hygiene issues and knows the principles of safety and comfort for this procedure. Monitoring the client, teaching techniques, and evaluating outcomes are nursing responsibilities. Focus: Delegation; QSEN: TC; Concept: Clinical Judgment

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

Ans: 3 The UAP can observe the amount that the patient eats (or what is gone from the tray) and report to the nurse. Assessing patterns of fatigue and skin reaction is the responsibility of the RN. The initial recommendation for exercise should come from the physician. Focus: Delegation; QSEN: TC; Concept: Clinical Judgment

The RN supervises a nursing assistive personnel (NAP). Which tasks will the nurse assign the NAP?

Assist the client diagnosed with myasthenia gravis during meal time

Which cancer patients could be placed together as roommates? Select all that apply. A. A patient who has a very low neutrophil count B. A patient who underwent debulking of a tumor to relieve pressure C. A patient who just underwent a bone marrow transplantation D. A patient who had a laminectomy for spinal cord compression E. A patient who is undergoing brachytherapy for prostate cancer F. A patient with terminal cancer who is receiving end-of-life care

B. A patient who underwent debulking of a tumor to relieve pressure D. A patient who had a laminectomy for spinal cord compression

The client has fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to unlicensed assistive personnel (UAP)? A. Administering IV fluids as prescribed by the physician B. Providing straws and offering fluids between meals C. Developing a plan for added fluid intake over 24 hours D. Teaching family members to assist the client with fluid intake

B. Providing straws and offering fluids between meals

The unlicensed assistive personnel (UAP) asks the nurse why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is the RN's best response? A. "The client's low phosphorus is probably due to malnutrition." B. "The client is just worn out from not getting enough rest." C. "The client's skeletal muscles are weak because of the low phosphorus." D. "The client will do more for himself when his phosphorus level is normal."

C. "The client's skeletal muscles are weak because of the low phosphorus."

The charge nurse discovers that two nurses have switched patients because Nurse A does "not like to take care of patients with prostate cancer." Which action should the charge nurse take first? A. Insist that they switch back to the original patient assignments and talk to each of them at the end of the shift. B. Allow them this flexibility; as long as the patients are well cared for, it doesn't matter if the assignments are changed. C. Ask Nurse A to explain her position regarding prostate cancer patients and seek alternatives to prevent future issues. D. Explain to Nurse A and B that all patients deserve kindness and care regardless of their condition or the nurses' personal feelings.

C. Ask Nurse A to explain her position regarding prostate cancer patients and seek alternatives to prevent future issues.

The unlicensed assistive personnel (UAP) reports to the nurse that a client seems very anxious, and vital sign measurement included a respiratory rate of 38 breaths/min. Which acid-base imbalance should the nurse suspect? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

C. Metabolic acidosis

The charge nurse of a long-term care facility is reviewing the methods and assessment tools that the staff nurses are using to assess pain. Which nurse is using the best method to assess pain? A. Nurse A uses a behavioral assessment tool when the client is engaged in activities. B. Nurse B asks a client who doesn't speak English to point to the location of pain. C. Nurse C uses the same numerical rating scale every day for the same client. D. Nurse D asks the daughter of a confused client to describe the client's pain.

C. Nurse C uses the same numerical rating scale every day for the same client.

A community health center is preparing a presentation on the prevention and detection of cancer. Which task would be best to assign to the LPN/LVN? A. Explain screening examinations and diagnostic testing for common cancers. B. Discuss how to plan a balanced diet and reduce fats and preservatives. C. Prepare a poster on the seven warning signs of cancer. D. Describe strategies for reducing risk factors such as smoking and obesity.

C. Prepare a poster on the seven warning signs of cancer.

A patient who has received a kidney transplant has been admitted to the medical unit with acute rejection and is receiving IV cyclosporine and methylprednisolone. Which staff member is best to assign to care for this patient? A. RN who floated to the medical unit from the coronary care unit for the day B. RN with 3 years of experience in the operating room who is orienting to the medical unit C. RN who has worked on the medical unit for 5 years and is working a double shift today D. Newly graduated RN who needs experience with IV medication administration

C. RN who has worked on the medical unit for 5 years and is working a double shift today

The nurse is reviewing a plan of care for a client who experienced a traumatic amputation of a leg the previous day. Which intervention listed on the plan is of lowest priority? 1 Teaching residual limb care 2 Monitoring hemoglobin levels 3 Maintaining the compression dressing 4 Using therapeutic interviewing techniques

1 Teaching residual limb care

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 thestudent 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. Respiratory rate of 8 to 10 breaths/min

The nurse is admitting an 8-month-old infant with suspected bacterial meningitis to the hospital. List in order of priority the nursing actions that would be taken. 1.Institute respiratory isolation. 2.Insert an intravenous access device. 3.Assist with a lumbar puncture. 4.Administer the prescribed antibiotics. 5.Monitor for signs of increased intracranial pressure (ICP).

1.Institute respiratory isolation. 2.Insert an intravenous access device. 3.Assist with a lumbar puncture. 4.Administer the prescribed antibiotics. 5.Monitor for signs of increased intracranial pressure (ICP).

14. The nursing diagnosis of Constipation related to compression of the intestinal tract has been identified in a patient with polycystic kidney disease. Which nursing care action should you delegate to a newly-trained LPN/LVN? 1. Instructing the patient about foods that are high in fiber 2. Teaching the patient about foods that assist in promoting bowel regularity 3. Assessing the patient for previous bowel problems and bowel routine 4. Administering docusate sodium (Colace) 100 mg by mouth twice a day

14. Ans: 4 Administering oral medications appropriately is covered in the educational program for LPNs/LVNs and is within their scope of practice. Teaching and assessing the patient require additional education and skill and are appropriate to the scope of practice of RNs. Focus: Delegation, supervision; QSEN: TC; Concept: Collaboration

Which is the priority nursing action for a client admitted to the hospital in a coma after having a stroke? 1 Monitor vital signs. 2 Maintain an open airway. 3 Maintain Fluids and Electrolytes. 4 Monitor pupil size and response.

2 Maintain an open airway.

A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. Which is the priority nursing intervention? 1 Increasing physical activities 2 Performing postural drainage 3 Maintaining dietary restrictions 4 Administering prescribed pancreatic enzymes

2 Performing postural drainage

A client is admitted to the emergency department with a stab wound of the chest. Which is a priority nursing assessment? 1 Level of pain 2 Quality and depth of respirations 3 Amount of serosanguinous drainage 4 Blood pressure and pupillary response

2 Quality and depth of respirations

The nurse is providing postoperative care to a client who is being weaned from mechanical ventilation. Which is a priority nursing action? 1 Assessing lung sounds every 15 minutes 2 Remaining with the client to assess responses 3 Monitoring the oxygen saturation levels frequently 4 Teaching the family members about ways to keep the client calm

2 Remaining with the client to assess responses

A client receiving chemotherapy develops a temperature of 102.2°F (39°C). The temperature 6 hours ago was 99.2°F (37.3°C). Which nursing intervention is the priority in this case? 1 Assess the amount and color of urine; obtain a specimen for a urinalysis and culture. 2 Administer the prescribed antipyretic and notify the primary health care provider of this change. 3 Note the consistency of respiratory secretions and obtain a specimen for culture and sensitivity. 4 Obtain the respirations, pulse, and blood pressure when rechecking the temperature in 1 hour.

2 Administer the prescribed antipyretic and notify the primary health care provider of this change.

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

22. Ans: 2, 3, 6 The clients with the cast, toe amputation, and arthritis are in stable condition and need ongoing assessment and pain management that are within the scope of practice of an LPN/LVN under the supervision of an RN. The RN should take responsibility for preoperative teaching, and the client with terminal cancer needs a comprehensive assessment to determine the reason for refusal of medication. The client with trauma needs serial assessments to detect occult trauma. Focus: Assignment; QSEN: TC; Concept: Clinical Judgment

A 23-year-old with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities included in the client's care will be best to delegate to an LPN/LVN whom you are supervising? (Select all that apply.) 1. Observing and documenting the onset and duration of any seizure activity 2. Administering phenytoin (Dilantin) 200 mg by mouth (PO) three times a day 3. Teaching the client about the need for frequent tooth brushing and flossing 4. Developing a discharge plan that includes referral to the Epilepsy Foundation . Assessing for adverse effects caused by new antiseizure medications

25. Ans: 1, 2 Any nursing staff member who is involved in caring for the client should observe for the onset and duration of any seizures (although a more detailed assessment of seizure activity should be done by the RN). Administration of medications is included in LPN/LVN education and scope of practice. Teaching, discharge planning, and assessment for adverse effects of new medications are complex activities that require RN-level education and scope of practice. Focus: Delegation; QSEN: TC, S; Concept: Collaboration

Based on the information in the chart of this client who came to the emergency department reporting pink-tinged urine, which nursing action is a priority? 1 Monitor the intake and output. 2 Take apical pulse for a full minute. 3 Institute measures to prevent physical injury. 4 Obtain stool specimen to test for occult blood.

3 Institute measures to prevent physical injury.

Which is the priority assessment for the client who has Guillain-Barré syndrome with rapidly ascending paralysis? 1 Monitoring urinary output 2 Assessing nutritional status 3 Monitoring respiratory status 4 Assessing communication needs

3 Monitoring respiratory status

The nurse on the pediatric unit is admitting an adolescent child with acute glomerulonephritis (AGN). Which is the priority nursing intervention? 1 Assessing the child for dysuria 2 Inspecting the child for jaundice 3 Monitoring the child for hypertension 4 Testing the child's vomitus for occult blood

3 Monitoring the child for hypertension

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. What are the priority nursing assessments? 1 Level of consciousness and pupil size 2 Characteristics of pain and blood pressure 3 Quality of respirations and presence of pulses 4 Observation of abdominal contusions and other wounds

3 Quality of respirations and presence of pulses

For a patient who is experiencing side effects of radiation therapy, which task would be the most appropriate to delegate to unlicensed assistive personnel (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. Reporting the amount and type of food consumed from the tray

A client with vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unti. Which action can be delegated to the UAP who is assisting with the client's care? 1. teaching the client and family members about means to prevent transmission of VRE 2. communicating with other departments when the client is transported for ordered tests 3. implementing contact precautions when providing care for the client 4. monitoring the results of ordered laboratory culture and sensitivity tests

3. implementing contact precautions when providing care for the client

A patient with a diagnosis of sleep apnea has a problem with sleep deprivation related to a disrupted sleep cycle. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? A. Discussing weight-loss strategies such as diet and exercise with the patient B. Teaching the patient how to set up the bilevel positive airway pressure (BiPAP) machine before sleeping C. Reminding the patient to sleep on his side instead of his back D. Administering modafinil to promote daytime wakefulness

NOT SURE? C. Reminding the patient to sleep on his side instead of his back

Which care activities, if performed correctly, would be in the delegation process? Select all that apply. One, some, or all responses may be correct. a. A licensed practical nurse (LPN) cleans the client's body b. An unlicensed assistive personnel (UAP) provides medication to the client c. An unlicensed assistive personnel (UAP) assists the client with oral feedings d. A licensed practical nurse (LPN) evaluates the client's temperature condition e. A registered nurse (RN) guides the unlicensed assistive personnel (UAP) while recording client's temperature

a. A licensed practical nurse (LPN) cleans the client's body c. An unlicensed assistive personnel (UAP) assists the client with oral feedings e. A registered nurse (RN) guides the unlicensed assistive personnel (UAP) while recording client's temperature

In a health care setting, there are a limited number of unlicensed nursing personnel (UNP). Which health care team member would take the responsibility of delegation in place of the registered nurse (RN)? a. Charge nurse b. Chief nursing officer c. Patient care associate d. Licensed practical nurse (LPN)

a. Charge nurse

Which challenges are faced by a health care team member in the process of delegation? Select all that apply. One, some, or all responses may be correct. a.Limited resources b. Large geographical area c. Time-saving considerations d. Vulnerable populations receiving care e. Provision of assistance with activities of daily living

a.Limited resources b. Large geographical area d. Vulnerable populations receiving care

The newly promoted registered nurse (RN) is about to start the process of delegation for the first time in his or her career. Which experiences foster professional self-confidence in the early career stage for an RN? Select all that apply. One, some, or all responses may be correct. a. Inability to comprehend b. Experience in clinical delegation c. Application of theory to practice d. Development of clinical judgment e. Engagement with a nursing mentor

b. Experience in clinical delegation c. Application of theory to practice d. Development of clinical judgment e. Engagement with a nursing mentor

The registered nurse (RN) suggested that the newly hired RN delegate tasks to nursing assistants. Which element fosters effective delegation decisions by the newly hired RN? a. Skills b. Stability c. Practice d. Environment

b. Stability

Which delegation right is being used when the nurse is considering whether the right equipment and resources are available to complete a task? a. Task b. Supervision c. Circumstance d. Communication

c. Circumstance

Which action is true as related to the role of the registered nurse (RN) in active delegation? a. Providing direct care to a client b. Performing the task on behalf of a delegatee c. Carrying out certain functions as the health care provider d. Directing an unlicensed practical nurse (UNP) to perform certain tasks

d. Directing an unlicensed practical nurse (UNP) to perform certain tasks