Thermo & delegation

B. Adjusts the bed to the Trendelenburg position. It is not safe to put the bed in the Trendelenburg position, because raising the foot increases blood flow to the brain, thereby increasing intracranial pressure. Temperature elevations may occur after a craniotomy because of stimulation of the hypothalamus. A hypothermic blanket should be ready if the temperature becomes precipitously elevated. Monitoring vital signs is a critical component of postoperative care. Intravenous infusions must be regulated precisely to minimize the possibility of cerebral edema.

A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when the child's nurse A. Places a hypothermia blanket at the bedside. B. Adjusts the bed to the Trendelenburg position. C. Obtains electronic equipment for monitoring the vital signs. D. Secures a pump to administer the ordered intravenous fluids.

A. Stupor. Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor, not erythema, would be present as a result of peripheral vasoconstriction. Drowsiness occurs; the patient would be unable to focus on anxiety-producing aspects of the situation. Respirations would be decreased.

A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for manifestations of hypothermia, including A. Stupor. B. Erythema. C. Increased anxiety. D. Rapid respirations

B - The registered nurse is legally responsible for client assignments and must assign tasks on the basis of the guidelines of nurse practice acts and the job description of the employing agency. A 2-day postoperative client who had a below-the-knee amputation will require both physiological and psychosocial care. A client scheduled to be discharged after coronary artery bypass surgery will require reinforcement of home care management. A client scheduled for a cardiac catheterization requires physiological needs and frequent nursing assessments. The nursing assistant has been trained to care for a client on bedrest and on urine collections. The nurse manager would provide instructions to the nursing assistant regarding the tasks, but the tasks required for this client are within the role description of a nursing assistan

A nurse manager is planning the client assignments for the day. Which of the following clients would the nurse assign to the nursing assistant? a) a 2-day postoperative client who had a below-the-knee amputation b) a client on a 24-hour urine collection who is on strict bedrest c) a cleint scheduled to be discharged after coronary artery bypass surgery d) a client scheduled for a cardiac catheterization

A. Core rewarming with warm fluids. Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The patient would be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gastric gavage is unnecessary.

A patient with hypothermia is brought to the emergency department. The nurse should explain to the family members that treatment will include A. Core rewarming with warm fluids. B. Ambulation to increase metabolism. C. Frequent oral temperature assessment. D. Gastric tube feedings to increase fluids.

Answer: A Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The patient would be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gastric gavage is unnecessary. where is core temp monitored?

A patient with hypothermia is brought to the emergency department. The nurse should explain to the family members that treatment will include A. Core rewarming with warm fluids. B. Ambulation to increase metabolism. C. Frequent oral temperature assessment. D. Gastric tube feedings to increase fluids.

D. Removing excess clothing. Rationale The priority nursing intervention would be removal of excess clothing. Seizures may occur because of a high body temperature, but seizure precautions should not be the first intervention. Oral intake, especially of fluids, should not be limited for a patient with hyperthermia, because of the dangers of dehydration. Blanketing, like clothing, should be removed.

A priority nursing intervention for a patient with hyperthermia would be A. Initiating seizure precautions. B. Limiting oral intake. C. Providing a blanket. D. Removing excess clothing.

D - The RN must not depend exclusively on the judgment of an LPN because the RN is responsible for supervising those to whom client care has been delegated. The client has recently had surgery, and there is the potential for complications, which may be signaled by alterations in vital signs and respiratory status. An analgesic may be needed, but in order to make that determination, the RN must have more information. A call to the surgeon may be warranted, but the RN has insufficient data at this time. In order to provide the client with the degree of care required, the nurse must assess the client, gather additional information, and analyze that information before notifying the surgeon.

A registered nurse (RN) has delegated care of a newly postoperative client to a licensed practical nurse (LPN). The LPN notifies the RN that the client's blood pressure and respirations are elevated from the baseline readings and that the client is complaining of pain and dyspnea. The RN takes which action next? a) the RN need not to carry out further assessment because the LPN is very experienced and trustworthy b) the RN requests that the LPN offer the client a opioid analgesic, which has ordered postoperatively c) the RN places a call to the attending surgeon and reports that the client is having pain and dyspneic d) the RN assesses the client, checks the client's surgical notes, and gathers addition data before calling the surgeon

A - In order to determine what can and cannot be delegated to a co-worker, several factors need to be considered. The nurse must carefully consider what level of care each client requires immediately and potentially in the future, what competencies are possessed by co-workers, and what legal limitations there are on the practice of those co-workers. In option 2, the client has undergone a serious neurosurgical procedure that can impair swallowing and gag reflexes, and there is significant risk of increased intracranial pressure in the first few days postoperatively. This and the fact that the client has been transferred from the ICU this morning make this an inappropriate assignment for an LPN. The LPN is also not able to provide discharge teaching on medications and treatments to a client. Teaching is a professional responsibility, which the RN cannot delegate to anyone except another RN, making option 3 incorrect. Although under some circumstances the RN might care for a client being discharged following chest pain, the question tells you that there is an LPN available. The RN would be best used to care for the client with more critical or complicated needs. Option 4 is therefore incorrect. The woman newly diagnosed with AIDS, who is unemployed and with small children, is likely to be in need of the skills of an RN in terms of both physiological and psychosocial needs, making option 1 an appropriate assignment.

A registered nurse (RN) must determine how best to assign coworkers (another RN and one licensed practical nurse LPN) to provide care to a group of clients. Which of the following is the appropriate assignment? a) the RN is assigned to care for an unemployed 26-year old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS), who has four school-age children b) the LPN is assigned to care for a 41-year old male, postresection of an acoustic neuroma 2 days ago, transferred from the intensive care unit (ICU) this morning c) the LPN is assigned to provide discharge teaching about medications and maintenance of nephrostomy tube to a 35-year old man d) the RN is assigned to care for a 65-year old woman hospitalized because of chest pain, being discharged today to home with no medication

ANS: D Slower metabolic rates are one factor that reduces the ability of older adults to regulate temperature and be comfortable when there are any temperature changes. As the body ages, the sweat glands decrease in number and efficiency. Older adults have reduced circulation

A volunteer at the senior center asks the visiting nurse why the senior citizens always seem to be complaining about temperatures. The nurse's best response is that older people have a diminished ability to regulate body temperature because of a.active sweat glands. b.increased circulation. c.peripheral vasoconstriction. d.slower metabolic rates.

1-Initiate the nursing care plan 3-Administer medications via metered-dose inhaler (MDI) 5-Auscultate breath sounds

An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply. 1-Initiate the nursing care plan 2-Evaluate the patient's technique for using MDI's 3-Administer medications via metered-dose inhaler (MDI) 4-Complete in-depth admission assessment 5-Auscultate breath sounds

Ans: 1, 2, 4 The experienced LPN/ LVN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/ LVN. Independently completing the admission assessment, developing the nursing care plan, and evaluating a patient's abilities require additional education and skills within the scope of practice of the professional RN. LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 175). Elsevier Health Sciences. Kindle Edition.

An experienced LPN/ LVN, under the supervision of the team leader RN, is providing 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.) 1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler (MDI) 3. Completing in-depth admission assessment 4. Checking oxygen saturation using pulse oximetry 5. Developing the nursing care plan 6. Evaluating the patient's technique for using MDIs

4-A 72-year old who needs teaching about the use of incentive spirometry

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit? 1-A 69-year old with COPD who is ventilator dependent 2-A 68-year old just returned from bronchoscopy and biopsy 3-A 58-year old on airborne precautions for tuberculosis (TB) 4-A 72-year old who needs teaching about the use of incentive spirometry

Ans: 2 UAPs can reinforce additional fluid intake once it is part of the care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice of an RN. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (pp. 171-172). Elsevier Health Sciences. Kindle Edition.

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

Ans: 1, 4, 6 Attaching cardiac monitor leads, obtaining an ECG, and administering oral medications are within the scope of practice for LPN/ LVNs. An experienced ED LPN/ LVN would be familiar with these activities. Although anticoagulants and narcotics may be administered by LPNs/ LVNs to stable clients, these are high-alert medications that should be given by the RN to this unstable client. Obtaining a pertinent medical history requires RN-level education and scope of practice. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 178). Elsevier Health Sciences. Kindle Edition.

The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to delegate to an experienced LPN/ LVN who is working with you in the ED? (Select all that apply.) 1. Attaching cardiac monitor leads 2. Giving heparin 5000 units IV push 3. Administering morphine sulfate 4 mg IV 4. Obtaining a 12-lead electrocardiogram (ECG) 5. Asking the client about pertinent medical history 6. Having the client chew and swallow aspirin 162 mg

D. Slow capillary refill. With hypothermia, there is slow capillary refill. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. The skin is usually pale or cyanotic with hypothermia.

The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates A. Increased respirations. B. Rapid pulse rate. C. Red, sweaty skin. D. Slow capillary refill.

Ans: 1, 2, 3, 4 The LPN/ LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPNs/ LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes, which contain alcohol, a drying agent. Initiating a dietary consult is within the purview of the RN or physician. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 172). Elsevier Health Sciences. Kindle Edition.

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

2-Observe how well the patient performs pursed-lip breathing

The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision? 1-Consult with the physical therapy department about reconditioning exercises 2-Observe how well the patient performs pursed-lip breathing 3-Plan a nursing care regimen that gradually increases activity intolerance 4-Assist the patient with basic activities of daily living

C. Increased pulse rate. pyrexia--> increased temp The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may increase but does not cause difficulty in breathing. Pain is not related to fever. Blood pressure is not necessarily elevated in fever.

What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia? A. Dyspnea. B. Precordial pain. C. Increased pulse rate. D. Elevated blood pressure.

1-A 63-year old with a tracheostomy needing tracheostomy care every shift. 2-A 38-year old with moderate persistent asthma awaiting discharge

You are acting as preceptor for a newly graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide care to which patients? Select all that apply. 1-A 63-year old with a tracheostomy needing tracheostomy care every shift. 2-A 38-year old with moderate persistent asthma awaiting discharge 3-A 49-year old just admitted with a new diagnosis of esophageal cancer. 4-A 56-year old with lung cancer who has just undergone left lower lobectomy

Ans: 1 Oral hygiene is within the scope of duties of the UAP. It is the responsibility of the nurse to observe response to treatments and to help the patient deal with loss or anxiety. The UAP can be directed to weigh the patient but should not be expected to know when to initiate that measurement. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 168). Elsevier Health Sciences. Kindle Edition.

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