Prioritization, Delegation, Assignment-Chapter 12

12. You are teaching the client and family how to perform colostomy irrigation. Place the following information in the correct order. 1. Hang the container at about shoulder height. 2. Allow the solution to flow slowly and steadily for 5 to 10 minutes. 3. Put 500 to 1000 mL of lukewarm water in the container. 4. Clip the irrigation sleeve and have the client walk for 30 to 45 minutes for secondary evacuation. 5. Lubricate the stoma cone and gently insert the tubing tip into the stoma. 6. Clean, rinse, and dry the skin, and apply a new drainage pouch. 7. Put on a pair of clean gloves. 8. Allow 15 to 20 minutes for the initial evacuation. _____, _____, _____, _____, _____, _____, ____, _____

12. Ans: 7, 3, 1, 5, 2, 8, 4, 6 7. Put on a pair of clean gloves. 3. Put 500 to 1000 mL of lukewarm water in the container. 1. Hang the container at about shoulder height. 5. Lubricate the stoma cone and gently insert the tubing tip into the stoma. 2. Allow the solution to flow slowly and steadily for 5 to 10 minutes. 8. Allow 15 to 20 minutes for the initial evacuation. 4. Clip the irrigation sleeve and have the client walk for 30 to 45 minutes for secondary evacuation. 6. Clean, rinse, and dry the skin, and apply a new drainage pouch. Putting on a pair of clean gloves protects the hands from colostomy secretions. The water should be warm (cold water can cause cramping) and the container should be hung at shoulder height (hanging the container too high or too low will alter the rate of flow). Lubricating the stoma and gently inserting the tubing tip will allow the water to flow into the stoma. A slow and steady flow prevents cramps and spillage. Providing adequate time allows for complete evacuation. Walking stimulates the bowel. Careful attention to the skin prevents breakdown. Focus: Prioritization

15. A client hospitalized with ulcerative colitis reports 10 to 20 small diarrhea stools per day, with abdominal pain before defecation. The client appears depressed and underweight and is uninterested in self-care or suggested therapies. What is the priority nursing diagnosis? 1. Diarrhea related to irritated bowel 2. Imbalanced Nutrition: Less than Body Requirements related to nutrient loss 3. Acute Pain related to increased GI motility 4. Ineffective Self-Health Management related to treatment plan"

15. Ans: 1 Diarrhea related to irritated bowel The immediate problem is controlling the diarrhea. Addressing this problem is a step toward correcting the nutritional imbalance and decreasing the diarrheal cramping. Self-care and compliance with the treatment plan are important long-term goals that can be addressed when the client is feeling better physically. Focus: Prioritization"

30. You are supervising a nursing student who is caring for a client who had a cholecystectomy. There is a T-tube in place. You would intervene if the student performs which action? 1. Maintains the client in a semi-Fowler position 2. Checks the amount, color, and consistency of the drainage 3. Gently aspirates the drainage from the tube 4. Inspects the skin around the tube for redness or irritation

30. Ans: 3 Gently aspirates the drainage from the tube T-tubes should not be irrigated, aspirated, or clamped without a specific order from the physician. All of the other actions are appropriate in the care of this client. Focus: Supervision

20. You are caring for a client with cirrhosis and portal hypertension. Which statement by the client concerns you the most? 1. "I'm very constipated and have been straining during bowel movements." 2. "I can't button my pants anymore because my belly is so swollen." 3. "I have a tight sensation in my lower legs when I forget to put my feet up." 4. "When I sleep, I have to sit in a recliner so that I can breathe more easily."

Ans: 1 "I'm very constipated and have been straining during bowel movements." There is a potential for sudden rupture of fragile blood vessels with massive hemorrhage from straining that increases thoracic or abdominal pressure. The client could have fluid accumulation in the abdomen (ascites) that can be mild and hard to detect or severe enough to cause orthopnea. Dependent peripheral edema can also be observed but is less urgent. Focus: Prioritization

22. A client underwent an exploratory laparotomy 2 days ago. The physician should be called immediately for which physical assessment finding? 1. Abdominal distention and rigidity 2. Displacement of the NG tube by the client 3. Absent or hypoactive bowel sounds 4. Nausea and occasional vomiting

Ans: 1 Abdominal distention and rigidity Distention and rigidity can signal hemorrhage or peritonitis. The physician may also decide that these symptoms require a medication to stimulate peristalsis. Absence of bowel sounds is expected within the first 24 to 48 hours. Nausea and vomiting are not uncommon and are usually self-limiting, and an "as needed" (PRN) order for an antiemetic is usually part of the routine postoperative orders. The reason for displacement of the NG tube should be assessed and the tube secured as necessary. Focus: Prioritization

8. You are providing immediate postoperative care for a client who had fundoplication to reinforce the lower esophageal sphincter for the purpose of a hiatal hernia repair. What is the priority action for the care of this client? 1. Elevate the head of the bed at least 30 degrees. 2. Assess the nasogastric tube for yellowish-green drainage. 3. Assist the client to start taking a clear liquid diet. 4. Assess the client for gas bloat syndrome.

Ans: 1 Elevate the head of the bed at least 30 degrees. The primary concern is the potential for airway complications. Elevating the head, at least 30 degrees, decreases the chance for aspiration and facilitates respiratory effort. The other options are also correct, but will occur later in the postoperative period. Focus: Prioritization

19. In the care of a client with acute viral hepatitis, which task should be delegated to the UAP? 1. Emptying the bedpan while wearing gloves 2. Playing games or engaging the client in diversional activities 3. Monitoring dietary preferences 4. Reporting signs and symptoms of jaundice

Ans: 1 Emptying the bedpan while wearing gloves The UAP should use infection control precautions for the protection of self, employees, and other clients. Monitoring is an RN responsibility. UAPs can report valuable information; however, they are not responsible for detecting signs and symptoms that can be subtle or hard to detect, such as skin changes. While playing games with the client may be ideal, it is rarely possible on a medical-surgical unit. Focus: Delegation

27. Clients who are undernourished or starved for prolonged periods are at risk for refeeding syndrome when nourishment is first given. What is the priority nursing assessment to prevent complications associated with this syndrome? 1. Monitor for peripheral edema, crackles in the lungs, and jugular vein distention. 2. Monitor for decreased bowel sounds, nausea, bloating, and abdominal distention. 3. Observe for signs of secret purging and ingestion of water to increase weight. 4. Assess for alternating constipation and diarrhea and pale clay-colored stools.

Ans: 1 Monitor for peripheral edema, crackles in the lungs, and jugular vein distention. Refeeding syndrome occurs when aggressive and rapid feeding results in fluid retention and heart failure. Electrolytes, especially phosphorus, should be monitored, and the client should be observed for signs of fluid overload. Changes in bowel sounds, nausea, and distention may occur but are also appropriate for any client with nutritional issues or for clients receiving enteral feedings. Observing for purging and water ingestion would be appropriate for a client with an eating disorder. Change in stool patterns may occur, but are not related to refeeding syndrome. Focus: Prioritization

21. For clients coming to the ambulatory care GI clinic, which task would be most appropriate to assign to an LPN/LVN? 1. Teaching a client self-care measures for an ulcer 2. Assisting the physician in incision and drainage of a pilonidal cyst 3. Evaluating a client's response to sitz baths for an anorectal abscess 4. Describing the basic pathophysiology of an anal fistula to a client

Ans: 2 Assisting the physician in incision and drainage of a pilonidal cyst Assisting with procedures for clients in stable condition with predictable outcomes is within the educational preparation of the LPN/LVN. Teaching the client about self-care or pathophysiology and evaluating the outcome of interventions are responsibilities of the RN. Focus: Delegation

5. You are taking an initial history for a client seeking surgical treatment for obesity. Which finding should be called to the attention of the surgeon before proceeding with additional history taking or physical assessment? 1. Obesity for approximately 5 years 2. History of counseling for body dysmorphic disorder 3. Failure to reduce weight with other forms of therapy 4. Body weight 100% above the ideal for age, gender, and height

Ans: 2 History of counseling for body dysmorphic disorder Body dysmorphic disorder is a preoccupation with an imagined physical defect. Corrective surgery can exacerbate this disorder when the client continues to feel dissatisfied with the results. The other findings are criterion indicators for this treatment. Focus: Prioritization

23. You must rearrange the room assignments for several clients. Which two clients would be best to put in the same room? 1. 35-year-old woman with copious intractable diarrhea and vomiting 2. 43-year-old woman who underwent cholecystectomy 2 days ago 3. 53-year-old woman with pain related to alcohol-associated pancreatitis 4. 62-year-old woman with colon cancer receiving chemotherapy and radiation _____, _____

Ans: 2, 3 2. 43-year-old woman who underwent cholecystectomy 2 days ago 3. 53-year-old woman with pain related to alcohol-associated pancreatitis Both clients will need frequent pain assessments and medications. Clients with copious diarrhea or vomiting will frequently need enteric isolation. Cancer clients receiving chemotherapy are at risk for immunosuppression and are likely to need protective isolation. Focus: Assignment

17. You are caring for an obese postoperative client who underwent surgery for bowel resection. As the client is moving in bed, he comments, "Something popped open." Upon examination you note wound evisceration. Place in order the steps for handling this complication. 1. Cover the intestine with sterile moistened gauze. 2. Stay calm and stay with the client. 3. Check the vital signs, especially blood pressure and pulse. 4. Have a colleague gather sterile supplies and contact the physician. 5. Put the client into semi-Fowler position with knees slightly flexed. 6. Prepare the client for surgery as ordered. _____, _____, _____, _____, _____, _____

Ans: 2, 5, 3, 4, 1, 6 2. Stay calm and stay with the client. 5. Put the client into semi-Fowler position with knees slightly flexed. 3. Check the vital signs, especially blood pressure and pulse. 4. Have a colleague gather sterile supplies and contact the physician. 1. Cover the intestine with sterile moistened gauze. 6. Prepare the client for surgery as ordered. Stay calm and stay with the client. Any increase in intra-abdominal pressure will worsen the evisceration; placement of the client in a semi-Fowler position with knees flexed will decrease the strain on the wound site. (Note: If shock develops, the client's head should be lowered.) Continuously monitor vital signs, particularly for a decrease in blood pressure or increase in pulse rate, while your colleague gathers supplies and notifies the physician. Covering the site protects tissue. Ultimately, the client will need emergency surgery. Focus: Prioritization

1. When a client is being prepared for a colonoscopy procedure, which task is most suitable to delegate to the UAP? 1. Explaining the need for a clear liquid diet 1 to 3 days before the procedure 2. Reinforcing "nothing by mouth" status 8 hours before the procedure 3. Administering laxatives 1 to 3 days before the procedure 4. Administering an enema the night before the procedure

Ans: 2. Reinforcing "nothing by mouth" status 8 hours before the procedure The UAP can reinforce dietary and fluid restrictions after the RN has explained the information to the client. It is also possible that the UAP can administer the enema; however, special training is required, and policies may vary among institutions. Medication administration should be performed by licensed personnel. Focus: Delegation

14. You are planning a treatment and prevention program for chronic fecal incontinence for an elderly client. Which intervention should you try first? 1. Administer a glycerin suppository 15 minutes before evacuation time. 2. Insert a rectal tube at specified intervals each day. 3. Assist the client to the bedpan or toilet 30 minutes after meals. 4. Use incontinence briefs or adult-sized diapers.

Ans: 3 Assist the client to the bedpan or toilet 30 minutes after meals. The goal of bowel training is to establish a pattern that mimics normal defecation, and many people have the urge to defecate after a meal. If this is not successful, a suppository can be used to stimulate the urge. The use of incontinence briefs is embarrassing for the client, and they must be changed frequently to prevent skin breakdown. Routine use of rectal tubes is not recommended because of the potential for damage to the mucosa and sphincter tone. Focus: Prioritization

10. The postoperative care of a morbidly obese client is being planned. Which task best utilizes the expertise of the LPN/LVN? 1. Obtaining an oversized blood pressure cuff and a large-size bed 2. Setting up a reinforced trapeze bar 3. Assisting in the planning of toileting, turning, and ambulation 4. Assigning tasks to UAPs and other ancillary staff

Ans: 3 Assisting in the planning of toileting, turning, and ambulation The LPN/LVN can assist in the planning of interventions, but the RN should take ultimate responsibility for planning. The LPN/LVN can delegate and assign tasks to UAPs; however, if the RN is in charge, it is better if UAPs are not receiving instructions from multiple people. Obtaining equipment should be delegated to a UAP. A physical therapist should be contacted to set up specialized equipment. Focus: Delegation

25. You are caring for a client who was admitted to your medical-surgical unit for observation after being evaluated in the emergency department for blunt trauma to the abdomen. Which instructions are appropriate to give to the UAP? 1. Check the client's skin temperature and report if the skin feels cool. 2. Check the urine in the urometer every hour and observe for red- or pink-tinged urine. 3. Check vital signs every hour and report all of the values. 4. Check the client's pain and report worsening of pain or discomfort.

Ans: 3 Check vital signs every hour and report all of the values. The UAP can take vital signs and report all of the values to the RN. In this case, all of the values are needed in order to detect trends. In other cases, you may decide to give parameters for reporting. The RN should assess skin temperature and pain, and closely monitor the urine because quantity is an indicator of perfusion and red/pink urine can signal damage to the urinary system, transfusion reaction, or rhabdomyolysis. Focus: Delegation

13. You are caring for a client with a nasogastric (NG) tube. Which task can be delegated to an experienced UAP? 1. Removing the NG tube per physician order 2. Securing the tape if the client accidentally dislodges the tube 3. Disconnecting the suction to allow ambulation to the toilet 4. Reconnecting the suction after the client has ambulated

Ans: 3 Disconnecting the suction to allow ambulation to the toilet Disconnecting the tube from suction is an appropriate task to delegate. Suction should be reconnected by the nurse, so that correct pressure is checked. If the UAP is permitted to reconnect the tube, the RN is still responsible for checking that the pressure setting is correct. During removal of the tube, there is a potential for aspiration, so the nurse should perform this task. If the tube is dislodged, the nurse should recheck placement before it is secured. Focus: Delegation

29. A client with end-stage liver disease is talking to you about being on the transplant list. Which statement by the client concerns you the most? 1. "I have a family history of diabetes." 2. "I had symptoms of asthma when I was a kid." 3. "I am going to cut down on my drinking very soon." 4. "I am not very good about taking prescribed medication."

Ans: 3 I am going to cut down on my drinking very soon." Substance abuse may exclude a person from the transplant list, so the nurse should conduct additional assessment about this comment. The comment about difficulty in taking prescription medications should also be investigated because a true inability to follow the treatment regimen would also exclude the client from the list. Focus: Prioritization

28. You are caring for a client who was admitted for advanced cirrhosis. The client has massive ascites, peripheral dependent edema in the lower extremities, nausea and vomiting, and dyspnea related to pressure on the diaphragm. For the nursing diagnosis of Excess Fluid Volume, which indicator is the most reliable for tracking fluid retention? 1. Auscultating the lung fields for crackles every day 2. Measuring the abdominal girth every morning 3. Performing daily weights with the same amount of clothing 4. Checking the extremities for pitting edema and comparing to baseline

Ans: 3 Performing daily weights with the same amount of clothing All of these measures should be performed for total care of the client; however weighing the client every day is considered the single best indicator of fluid volume. Focus: Prioritization

7. In the care of a client with gastroesophageal reflux disease, which task would be appropriate to assign to a UAP? 1. Sharing successful strategies for weight reduction 2. Encouraging the client to express concerns about lifestyle modification 3. Reminding the client not to lie down for 2 to 3 hours after eating 4. Explaining the rationale for eating small frequent meals

Ans: 3 Reminding the client not to lie down for 2 to 3 hours after eating Reminding the client to follow through on advice given by the nurse is an appropriate task for the UAP. The RN should take responsibility for teaching rationale, discussing strategies for the treatment plan, and assessing client concerns. Focus: Delegation

18. You are providing postoperative care for a client who underwent laparoscopic cholecystectomy. What should be reported immediately to the physician? 1. The client cannot void 5 hours postoperatively. 2. The client reports shoulder pain. 3. The client reports right upper quadrant pain. 4. Output does not equal input for the first few hours.

Ans: 3 The client reports right upper quadrant pain. Right upper quadrant pain is a sign of hemorrhage or bile leak. The ability to void should return within 6 hours postoperatively. Right shoulder pain is related to unabsorbed carbon dioxide and will be resolved by placing the client in Sims position. Output that does not equal input after surgery for the first several hours is expected. Focus: Prioritization

16. While transferring a dirty laundry bag, a UAP sustains a puncture wound to the finger from a contaminated needle. The unit has several clients with hepatitis and acquired immunodeficiency syndrome (AIDS); the needle source is unknown. Place in order of priority the instructions that should be given to the UAP. 1. Have blood test(s) performed per protocol. 2. Complete and file an incident report. 3. Perform a thorough aseptic hand washing. 4. Report to the occupational health nurse. 5. Follow up for results and counseling. 6. Begin prophylactic drug therapy. _____, _____, _____, _____, _____, _____

Ans: 3, 4, 1, 2, 6, 5 3. Perform a thorough aseptic hand washing. 4. Report to the occupational health nurse. 1. Have blood test(s) performed per protocol. 2. Complete and file an incident report. 6. Begin prophylactic drug therapy. 5. Follow up for results and counseling. Immediate decontamination is appropriate, because time can affect viral load. The occupational health nurse will direct the UAP in filing the correct forms, getting the appropriate laboratory tests, obtaining appropriate prophylaxis, and following up on results. Focus: Prioritization, supervision

9. Which client is the most appropriate to assign to an LPN/LVN, under the supervision of an RN? 1. Client with oral cancer who is scheduled in the morning for glossectomy 2. Obese client returned from surgery after a vertical banded gastroplasty 3. Client with anorexia nervosa who has muscle weakness and decreased urine output 4. Client with intermittent nausea and vomiting related to chemotherapy

Ans: 4 Client with intermittent nausea and vomiting related to chemotherapy Nausea and vomiting are common after chemotherapy. Administration of antiemetics and fluid monitoring can be done by an LPN/LVN. The RN should perform the preoperative teaching for the glossectomy client. Clients returning from surgery need extensive assessment. The client with anorexia is showing signs of hypokalemia and is at risk for cardiac dysrhythmias. Focus: Assignment

2. You would be most concerned about an order for a total parenteral nutrition (TPN) fat emulsion for a client with which condition? 1. Gastrointestinal (GI) obstruction 2. Severe anorexia nervosa 3. Chronic diarrhea and vomiting 4. Fractured femur

Ans: 4 Fractured femur A client with a fractured femur is at risk for fat embolism, so a fat emulsion should be used with caution. Vomiting may be a problem if the emulsion is infused too rapidly. TPN is commonly used in clients with GI obstruction, severe anorexia nervosa, and chronic diarrhea or vomiting. Focus: Prioritization

11. A client with proctitis needs a rectal suppository. A senior nursing student assigned to care for this client tells you that she is afraid to insert a suppository because she has never done it before. What is the most appropriate action in supervising this student? 1. Give the medication yourself and tell the student to talk to the instructor. 2. Ask the student to leave the clinical area because she is unprepared. 3. Reassign the client to an LPN/LVN and send the student to observe. 4. Show the student how to insert the suppository and talk to the instructor.

Ans: 4 Show the student how to insert the suppository and talk to the instructor. Showing the student how to insert the suppository meets both the immediate client need and the student's learning need. The instructor can address the student's fears and long-term learning needs once he or she is aware of the incident. It is preferable that students express fears and learning needs. The other options will discourage the student's future disclosure of clinical limitations and need for additional training. Focus: Supervision, assignment

24. You are caring for a client who was recently admitted for severe diverticulitis. Which task is appropriate to delegate for the care of this client? 1. Tell the unit secretary to call radiology and schedule a barium enema. 2. Instruct the LPN/LVN to give PRN laxatives when the client reports constipation. 3. Advise the nursing student to help the client ambulate up and down the hall. 4. Tell the UAP that a stool specimen must be saved to test for occult blood.

Ans: 4 Tell the UAP that a stool specimen must be saved to test for occult blood. Diverticulitis can cause chronic or severe bleeding, so if there is no obvious blood in the stool, the stool may be tested for occult blood. A barium enema is not usually ordered because of the danger of perforation. Laxatives and ambulation increase intestinal motility and are to be avoided in the initial phase of treatment. If a barium enema, PRN laxative, or ambulation is ordered, question the orders before delegating these interventions. Focus: Delegation

6. You are taking report on an elderly client who was admitted with abdominal pain and nausea, vomiting, and diarrhea. The client also has a history of chronic dementia. Which comment by the night shift nurse concerns you the most? 1. The client has a flat affect and rambling and repetitive speech. 2. The client has memory impairments and thinks the year is 1948. 3. The client lacks motivation and demonstrates early morning awakening. 4. The client has a fluctuating level of consciousness and mood swings.

Ans: 4 The client has a fluctuating level of consciousness and mood swings. Fluctuating level of consciousness and mood swings are associated more with acute delirium, which could be caused by many things, such as electrolyte imbalances, sepsis, or medications. Information about the client's baseline behavior is essential; however, based on your knowledge of pathophysiology, you know that flat affect and rambling and repetitive speech, memory impairments, and disorientation to time are behaviors typically associated with chronic dementia. Lack of motivation and early morning awakening are associated with depression. Focus: Prioritization

4. You are caring for a client with peptic ulcer disease. Which assessment finding is the most serious? 1. Projectile vomiting 2. Burning sensation 2 hours after eating 3. Coffee-ground emesis 4. Boardlike abdomen with shoulder pain

Ans: 4. Boardlike abdomen with shoulder pain A boardlike abdomen with shoulder pain is a symptom of a perforation, which is the most lethal complication of peptic ulcer disease. A burning sensation is a typical complaint and can be controlled with medications. Projectile vomiting can signal an obstruction. Coffee-ground emesis is typical of slower bleeding, and the client will require diagnostic testing. Focus: Prioritization

26. Place the steps for performing colostomy care in the correct order. 1. Fit the pouch snugly around the stoma. 2. Assess the color and appearance of the stoma. 3. Wash the skin with mild soap and rinse with warm water. 4. Apply a skin barrier to protect the peristomal skin. 5. Dry the skin carefully. 6. Don a pair of clean gloves and remove the old pouch. _____, ____, _____, _____, _____, _____

Ans: 6, 2, 3, 5, 4, 1 6. Don a pair of clean gloves and remove the old pouch. 2. Assess the color and appearance of the stoma. 3. Wash the skin with mild soap and rinse with warm water. 5. Dry the skin carefully. 4. Apply a skin barrier to protect the peristomal skin. 1. Fit the pouch snugly around the stoma. A pair of clean gloves should be put on before touching the skin or pouch. The stoma should be assessed for a healthy pink color. Washing, rinsing, and drying the skin and applying a skin barrier help to protect the skin. A good fit prevents gastric contents from spilling onto the skin. Focus: Prioritization

3. You are preparing to administer TPN through a central line. Place the following steps for administration in the correct order. 1. Use aseptic technique when handling the injection cap. 2. Thread the IV tubing through an infusion pump. 3. Check the solution for cloudiness or turbidity. 4. Connect the tubing to the central line. 5. Select and flush the correct tubing and filter. 6. Set the infusion pump at the prescribed rate. 7. Confirm the order for TPN prior to administration. _____, _____, _____, _____, _____, _____, _____

Ans: 7, 3, 5, 2, 1, 4, 6 7. Confirm the order for TPN prior to administration. 3. Check the solution for cloudiness or turbidity. 5. Select and flush the correct tubing and filter. 2. Thread the IV tubing through an infusion pump. 1. Use aseptic technique when handling the injection cap. 4. Connect the tubing to the central line. 6. Set the infusion pump at the prescribed rate. Always check the order before administering TPN; generally, each bag is individually prepared by the pharmacist. The solution should not be cloudy or turbid. Prepare the equipment by priming the tubing and threading the pump. To prevent infection, scrub the hub and use aseptic technique when inserting the connector into the injection cap and connecting the tubing to the central line. Set the pump at the prescribed rate. Focus: Prioritization