Chapter 4 - Prioritization, Delegation, and Assignment

The client described in question 3 is also at risk for poor perfusion related to decreased plasma volume. Which assessment finding supports this risk? •Flattened neck veins when the client is in the supine position •Full and bounding pedal and post-tibial pulses •Pitting edema located in the feet, ankles, and calves •Shallow respirations with crackles on auscultation

•Flattened neck veins when the client is in the supine position •Normally, neck veins are distended when the client is in the supine position. These veins flatten as the client moves to a sitting position. The other three responses are characteristic of excess fluid volume.

Which order prescribed for a client with hypercalcemia would the nurse be sure to question? •0.9% saline at 50 mL/hr IV •Furosemide 20 mg orally each morning •Apply cardiac telemetry monitoring •Hydrochlorothiazide (HCTZ) 25 mg orally each morning

•Hydrochlorothiazide (HCTZ) 25 mg orally each morning •Calcium excretion is decreased with thiazide diuretics (e.g., HCTZ), so the calcium level is at risk for going even higher. Loop diuretics (e.g., furosemide) increase calcium excretion. The addition of IV fluids and cardiac monitoring are appropriate actions for monitoring and treating a client with hypercalcemia.

A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would the nurse be sure to monitor? •Hypokalemia •Hyperkalemia •Hyponatremia •Hypernatremia

•Hyponatremia •SIADH results in a relative sodium deficit caused by excessive retention of water.

The RN is providing care for a client diagnosed with dehydration and hypovolemic shock. Which prescribed intervention from the health care provider should the RN question? •Blood pressure every 15 minutes •Place two 18-gauge IV lines •Oxygen at 3 L via nasal cannula •IV 5% dextrose in water (D5W) to run at 250 mL/hr

•IV 5% dextrose in water (D5W) to run at 250 mL/hr •To correct hypovolemic shock with dehydration, the client needs IV fluids that are isotonic and will increase intravascular volume, such as normal saline. With D5W, the body rapidly metabolizes the dextrose and the solution becomes hypotonic. All of the other interventions are appropriate for a client with shock.

The client with respiratory failure is receiving mechanical ventilation and continues to produce arterial blood gas results indicating respiratory acidosis. Which change in ventilator setting should the nurse expect to correct this problem? •Increase in ventilator rate from 6 to 10 breaths/min •Decrease in ventilator rate from 10 to 6 breaths/min •Increase in oxygen concentration from 30% to 40% •Decrease in oxygen concentration from 40% to 30%

•Increase in ventilator rate from 6 to 10 breaths/min •The blood gas component responsible for respiratory acidosis is carbon dioxide, thus increasing the ventilator rate will blow off more carbon dioxide and decrease or correct the acidosis. Changes in the oxygen setting may improve oxygenation but will not affect respiratory acidosis.

Which specific instruction does the charge nurse give the unlicensed assistive personnel (UAP) helping to provide care for a client who is at risk for metabolic acidosis? •Check to see that the client keeps his oxygen in place at all times •Inform the nurse immediately if the client's respiratory rate and depth increases •Record any episodes of reflux or constipation •Keep the client's ice water pitcher filled at all times

•Inform the nurse immediately if the client's respiratory rate and depth increases •If acidosis is metabolic in origin, the rate and depth of breathing increase as the hydrogen ion level rises. Breaths are deep and rapid and not under voluntary control, a pattern called Kussmaul respiration. The client may not require oxygen. Although it's important to record reflux and constipation, this is not related to metabolic acidosis nor is keeping the water pitcher full specific to this condition.

The RN is admitting a client with benign prostatic hyperplasia (BPH) to an acute care unit. The client describes an oral intake of about 1400 mL/day. What is the RN's *priority* concern? •Ask the client about his or her bowel movements •Have the client complete a diet diary for the past 2 days •Instruct the client to increase oral intake to 2 to 3 L/day •Ask the client to describe his urine output

•Instruct the client to increase oral intake to 2 to 3 L/day •An adult should take in about 2 to 3 L of fluid daily from food and liquids. Although the RN would want to know about bowel movements, dietary intake, and urine output, in this case, the priority is that the client is not taking in enough oral fluids.

The nurse is caring for a client who experiences frequent generalized tonic-clonic seizures associated with periods of apnea. The nurse must be alert for which acid-base imbalance? •Respiratory alkalosis •Respiratory acidosis •Metabolic alkalosis •Metabolic acidosis

•Metabolic acidosis •Seizures may be associated with apnea and thus hypoxemia and lactic acidosis. Lactic acidosis, a form of metabolic acidosis, occurs when cells use glucose without adequate oxygen (anaerobic metabolism); glucose then is incompletely broken down and forms lactic acid. This acid releases hydrogen ions, causing acidosis. Lactic acidosis occurs whenever the body has too little oxygen to meet metabolic oxygen demands (e.g., heavy exercise, seizure activity, reduced oxygen).

The nurse has been floated to the telemetry unit for the day. The monitor technician informs the nurse that the client has developed prominent U waves. Which laboratory value should be checked *immediately*? •Sodium •Potassium •Magnesium •Calcium

•Potassium •Suspect hypokalemia and check the client's potassium level. Common ECG changes with hypokalemia include ST-segment depression, inverted T waves, and prominent U waves. Clients with hypokalemia may also develop heart block. Other abnormal electrolyte levels can affect cardiac rhythms, but the occurrence of U waves is associated with low potassium levels.

Which blood test result would the nurse be sure to monitor for the client taking hydrochlorothiazide (HCTZ)? •Sodium level •Potassium level •Chloride level •Calcium level

•Potassium level •Potassium is lost when a client is taking HCTZ, and potassium level should be monitored regularly.

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.* •Providing oral care every 3 to 4 hours •Monitoring for indications of dehydration •Administering 0.45% saline by IV line •Record urine output when client voids •Assessing daily weights for trends •Help the client change position every 2 hours

•Providing oral care every 3 to 4 hours •Record urine output when client voids •Help the client change position every 2 hours •Providing oral care, assisting clients to reposition, and recording urine output are within the scope of practice of the UAP. Monitoring and assessing clients, as well as administering IV fluids, require the additional education and skills of the RN.

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)? •Administering IV fluids as prescribed by the physician •Providing straws and offering fluids between meals •Developing a plan for added fluid intake over 24 hours •Teaching family members to assist the client with fluid intake

•Providing straws and offering fluids between meals •UAPs can reinforce additional fluid intake when 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.

Which actions should the nurse delegate to an unlicensed assistive personnel (UAP) for the client with diabetic ketoacidosis? *Select all that apply.* •Checking fingerstick glucose results every hour •Recording intake and output every hour •Measuring vital signs every 15 minutes •Assessing for indicators of fluid imbalance •Notifying the provider of changes in glucose level •Assisting the client to reposition every 2 hours

•Recording intake and output every hour •Measuring vital signs every 15 minutes •Assisting the client to reposition every 2 hours •The UAP's training and education includes how to measure vital signs, record intake and output, and reposition clients. Performing fingerstick glucose checks and assessing clients requires additional education and skill, as possessed by licensed nurses. Notifying the provider of glucose changes is within the scope of practice for licensed nurses. Some facilities may train experienced UAPs to perform fingerstick glucose checks and change their role descriptions to designate their new skills, but this task is beyond the normal scope of practice of a UAP.

The nursing care plan for an older 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.* •Reminding the client to avoid commercial mouthwashes •Encouraging mouth rinsing with warm saline •Assess skin turgor by pinching the skin over the back of the hand •Observing the lips, tongue, and mucous membranes •Providing mouth care every 2 hours while the client is awake •Seeking a dietary consult to increase fluids on meal trays

•Reminding the client to avoid commercial mouthwashes •Encouraging mouth rinsing with warm saline •Observing the lips, tongue, and mucous membranes •Providing mouth care every 2 hours while the client is awake •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 agents such as alcohol. To assess skin turgor in an older adult, skin tenting is best checked by pinching the skin over the sternum or on the forehead rather than the back of the hand. With aging, the skin loses elasticity and tents on hands and arms even when the adult is well hydrated. Initiating a dietary consult is within the purview of the RN or health care provider.

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? •Repeated episodes of nausea and vomiting •Reports of pain associated with exertion •Failure to eat all the food on the breakfast tray •Client hair loss during the morning bath

•Repeated episodes of nausea and vomiting •Prolonged nausea and vomiting can result in acid deficit that can lead to metabolic alkalosis. The other findings are important and need to be assessed but are not related to acid-base imbalances.

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? •Respiratory acidosis •Respiratory alkalosis •Metabolic acidosis •Metabolic alkalosis

•Respiratory alkalosis •The client is most likely hyperventilating and blowing off carbon dioxide. This decrease in carbon dioxide will lead to an increase in pH and cause respiratory alkalosis. Eliminating carbon dioxide would lead to an alkalosis. Metabolic imbalances would be related to renal changes.

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

•Respiratory rate of 8 to 10 breaths/min •A decreased respiratory rate indicates respiratory depression, which also puts the client at risk for respiratory acidosis. All of the other findings are important and should be reported to the RN, but the respiratory rate demands urgent attention.

An experienced LPN/LVN reports to the RN that a client's blood pressure and heart rate have decreased, and when his face was assessed, one side twitches. What action should the RN take at this time? •Reassess the client's blood pressure and heart rate •Review the client's morning calcium level •Request a neurologic consult today •Check the client's pupillary reaction to light

•Review the client's morning calcium level •A positive Chvostek sign (facial twitching of one side of the mouth, nose, and cheek in response to tapping the face just below and in front of the ear) is a neurologic manifestation of hypocalcemia. The heart rate may be slower or slightly faster than normal, with a weak, thready pulse. Severe hypocalcemia causes severe hypotension. The LPN/LVN is experienced and possesses the skills to accurately measure vital signs.

The RN is reviewing the client's morning laboratory results. Which of these results is of *most* concern? •Serum potassium level of 5.2 mEq/L (5.2 mmol/L) •Serum sodium level of 134 mEq/L (134 mmol/L) •Serum calcium level of 10.6 mg/dL (2.65 mmol/L) •Serum magnesium level of 0.8 mEq/L (0.4 mmol/L)

•Serum magnesium level of 0.8 mEq/L (0.4 mmol/L) •Although all of these laboratory values are outside of the normal range, the magnesium level is furthest from normal. With a magnesium level this low, the client is at risk for ECG changes and life-threatening ventricular dysrhythmias.

The nurse is preparing to discharge a client whose calcium level was low but is now just barely within the normal range (9 to 10.5 mg/dL [2.25 to 2.63 mmol/L]). Which statement by the client indicates the need for additional teaching? •"I will call my doctor if I experience muscle twitching or seizures." •"I will make sure to take my vitamin D with my calcium each day." •"I will take my calcium citrate pill every morning before breakfast." •"I will avoid dairy products, broccoli, and spinach when I eat."

•"I will avoid dairy products, broccoli, and spinach when I eat." •Clients with low calcium levels should be encouraged to eat dairy products, seafood, nuts, broccoli, and spinach, which are all good sources of dietary calcium. The other three options indicate correct understanding of calcium therapy.

Which statement by a client with hypovolemia related to dehydration is the *best* indicator to the nurse of the need for additional teaching? •"I will drink 2 to 3 L of fluids every day." •"I will drink a glass of water whenever I feel thirsty." •"I will drink coffee and cola drinks throughout the day." •"I will avoid drinks containing alcohol."

•"I will drink coffee and cola drinks throughout the day." •Mild dehydration is very common among healthy adults and is corrected or prevented easily by matching fluid intake with fluid output. Teach all adults to drink more fluids, especially water. Beverages with caffeine can increase fluid loss, as can drinks containing alcohol. These beverages should not be used to prevent or treat dehydration.

The client has an order for hydrochlorothiazide (HCTZ) 10 mg orally every day. What should the nurse be sure to include in a teaching plan for this drug? *Select all that apply.* •"Take this medication in the morning." •"This medication should be taken in two divided doses when you get up and when you go to bed." •"Eat foods with extra sodium every day." •"Inform your prescriber if you notice weight gain or increased swelling." •"You should expect your urine output to increase." •"Your health care provider may also prescribe a potassium supplement."

•"Take this medication in the morning." •"Inform your prescriber if you notice weight gain or increased swelling." •"You should expect your urine output to increase." •"Your health care provider may also prescribe a potassium supplement." •HCTZ is a thiazide diuretic. It should not be taken at night because it will cause the client to wake up to urinate. This type of diuretic causes a loss of potassium, so the nurse should teach the client about eating foods rich in potassium and that the health care provider may prescribe a potassium supplement. Weight gain and increased edema should not occur while the client is taking this drug, so these should be reported to the prescriber.

The client has a nasogastric (NG) tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate and depth has decreased. What is the nurse's *best* response? •"It's common for clients with uncomfortable equipment such as NG tubes to have a lower rate of breathing." •"The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism." •"Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps correct the problem." •"The client is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis."

•"The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism." •Nasogastric suctioning can result in a decrease in acid components and metabolic alkalosis. The client's decrease in rate and depth of ventilation is an attempt to compensate by retaining carbon dioxide. The first response may be true, but it does not address all the components of the question. The third and fourth answers are inaccurate.

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? •"The client's low phosphorus is probably due to malnutrition." •"The client is just worn out from not getting enough rest." •"The client's skeletal muscles are weak because of the low phosphorus." •"The client will do more for himself when his phosphorus level is normal."

•"The client's skeletal muscles are weak because of the low phosphorus." •A musculoskeletal manifestation of low phosphorus levels is generalized muscle weakness, which may lead to acute muscle breakdown (rhabdomyolysis). Phosphate is necessary for energy production in the form of adenosine triphosphate, and when not produced, leads to generalized muscle weakness. Although the other statements are true, they do not answer the UAP's question.

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? •"When the Paco2 is acutely elevated, the blood pH should be lower than normal." •"This client should be taught to breathe and rebreathe in a paper bag." •"An elevated Paco2 always means that a client has an acidosis." •"When a client's Paco2 is increased, the respiratory rate should decrease to compensate."

•"When the Paco2 is acutely elevated, the blood pH should be lower than normal." •This client's Paco2 is elevated (normal is 35 to 45 mm Hg). Whenever the Paco2 level changes acutely, the pH changes to the same degree, in the opposite direction. As the amount of CO2 begins to rise above normal in brain blood and tissues, these central receptors trigger the neurons to increase the rate and depth of breathing (hyperventilation). For these reasons, answers 2, 3, and 4 are inaccurate.

The nurse is completing a history for an older client at risk for an acidosis imbalance. Which questions would the nurse be sure to ask? *Select all that apply.* •"Which drugs to you take on a daily basis?" •"Do you have any problems with breathing?" •"When was your last bowel movement?" •"Have you experienced any activity intolerance or fatigue in the past 24 hours?" •"Over the past month have you had any dizziness or tinnitus?" •"Do you have episodes of drowsiness or decreased alertness?"

•"Which drugs to you take on a daily basis?" •"Do you have any problems with breathing?" •"Have you experienced any activity intolerance or fatigue in the past 24 hours?" •"Do you have episodes of drowsiness or decreased alertness?" •Collect data about risk factors related to the development of acidosis. Older adults may be taking drugs that disrupt acid-base balance, especially diuretics and aspirin. Ask about specific risk factors, such as any type of breathing problem. Also ask about headaches, behavior changes, increased drowsiness, reduced alertness, reduced attention span, lethargy, anorexia, abdominal distention, nausea or vomiting, muscle weakness, and increased fatigue. Ask the client to relate activities of the previous 24 hours to identify activity intolerance, behavior changes, and fatigue. Answers 3 and 5 are not common concerns with acidosis.

The nurse is providing care for several clients who are at risk for acid-base imbalance. Which client is *most* at risk for respiratory acidosis? •A 68-year-old client with chronic emphysema •A 58-year-old client who uses antacids every day •A 48-year-old client with an anxiety disorder •A 28-year-old client with salicylate intoxication

•A 68-year-old client with chronic emphysema •Clients at greatest risk for acute acidosis are those with problems that impair breathing. Older adults with chronic health problems are at greater risk for developing acidosis. Whereas a client who misuses antacids is at risk for metabolic alkalosis, a client with anxiety is at risk for respiratory alkalosis. A client with salicylate intoxication is at risk for metabolic acidosis.

Which client would the charge nurse assign to the step-down unit nurse who was floated to the intensive care unit for the day? •A 68-year-old client on a ventilator with acute respiratory failure and respiratory acidosis •A 72-year-old client with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent •A newly admitted 56-year-old client with diabetic ketoacidosis receiving an insulin drip •A 38-year-old client on a ventilator with narcotic overdose and respiratory alkalosis

•A 72-year-old client with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent •The client with COPD, although ventilator dependent, is in the most stable condition of the clients in this group and should be assigned to the float nurse from the step-down unit. Clients with acid-base imbalances often require frequent laboratory assessment and changes in therapy to correct their disorders. In addition, the client with diabetic ketoacidosis is a new admission and require an in-depth admission assessment. All three of these clients need care from an experienced critical care nurse.

The health care provider has written these orders for a client with a diagnosis of pulmonary edema. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes *priority* at this time? •Weigh the client every morning •Maintain accurate intake and output records •Restrict fluids to 1500 mL/day •Administer furosemide 40 mg IV push

•Administer furosemide 40 mg IV push •Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. The other orders are important but are not urgent.

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? •Administer sodium polystyrene sulfonate 15 g orally •Administer spironolactone 25 mg orally •Assess the electrocardiogram (ECG) strip for tall T waves •Administer potassium 10 mEq (10 mmol/L) orally

•Administer sodium polystyrene sulfonate 15 g orally •The client's potassium level is high (normal range is 3.5 to 5 mEq/L or 3.5 to 5 mmol/L). Sodium polystyrene sulfonate removes potassium from the body through the gastrointestinal system. Spironolactone is a potassium-sparing diuretic that may cause the client's potassium level to go even higher. A KCl supplement can also raise the potassium level even higher. The beginning nursing student does not have the skill to assess ECG strips.

The nurse is admitting an older adult client to the acute care medical unit. Which assessment factor alerts the nurse that this client has a risk for acid-base imbalances? •History of myocardial infarction (MI) 1 year ago •Antacid use for occasional indigestion •Shortness of breath with extreme exertion •Chronic renal insufficiency

•Chronic renal insufficiency •Risk factors for acid-base imbalances in older adults include chronic kidney disease and pulmonary disease. Occasional antacid use will not cause imbalances, although antacid abuse is a risk factor for metabolic alkalosis. The MI occurred 1 year ago and is no longer a risk factor.

The unlicensed assistive personnel (UAP) reports to the nurse that a client's urine output for the past 24 hours has been only 360 mL. What is the nurse's *priority* action at this time? •Place an 18-gauge IV in the nondominant arm •Elevate the client's head of bed at least 45 degrees •Instruct the UAP to provide the client with a pitcher of ice water •Contact and notify the health care provider immediately

•Contact and notify the health care provider immediately •The minimum amount of urine per day needed to excrete toxic waste products is 400 to 600 mL. This minimum volume is called the obligatory urine output. If the 24-hour urine output falls below the obligatory output amount, wastes are retained and can cause lethal electrolyte imbalances, acidosis, and a toxic buildup of nitrogen. The client may need additional fluids (IV or oral) after the cause of the low urine output is determined. Elevating the head of the bed will not help with urine output. Notifying the health care provider is the first priority in this case.