Focus on Delegating Prioritizing Triage Disaster

A registered nurse (RN) on the night shift has a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP)on the team and is planning the client assignments for the night. Which client does the RN assign to the LPN?

A client with a nasogastric tube who underwent bowel resection 2 days ago. A client who has been fitted with skeletal traction of the right leg after an open reduction measures. When a nurse delegates aspects of a client's care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. An LPN may perform certain invasive procedures. A client with a nasogastric tube who underwent bowel resection 2 days ago and a client in skeletal traction to the right leg after open reduction may safely be assigned to the LPN, because the LPN is capable of performing the nasogastric tube care, dressing changes, and monitoring for postoperative complications that the clients will require. Interventions such as assisting clients with ambulation and hygiene measures and performing noninvasive procedures — the types of tasks identified in the other options — may be assigned to a nursing assistant.

A registered nurse (RN) is planning assignments for six clients on a nursing unit. The RN has an RN, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) on the nursing team. Which clients should the nurse assign to the RN?

A client with newly diagnosed type 1 diabetes mellitus. A client with GI bleeding and a Hgb of 7.3. A client who was admitted during the night after an acute asthma attack. When delegating nursing assignments, the nurse must consider the skills and educational level of the nursing staff. The client with newly diagnosed type 1 diabetes mellitus will require significant education, which should be provided by the RN. The client with gastrointestinal bleeding and a low hemoglobin level will likely require a blood transfusion, which must be performed by the RN. The client who was admitted to the hospital during the night after an acute asthma attack would most appropriately be assigned to the RN, because frequent respiratory assessments will be required. The UAP can most appropriately assist with personal care. The LPN can perform dressing changes and administer enemas.

A home care nurse is assigned to visit a prenatal client with a diagnosis of hyperemesis gravidarum (HEG). During physical assessment of the client, the nurse should first:

Assess the client's intake and output. HEG is persistent, uncontrolled vomiting that begins before the 20th week of pregnancy. It can have serious consequence, including loss of 5% of prepregnancy weight, dehydration, ketosis, acid-base imbalance, and electrolyte imbalances. Physical assessment begins with determining the client's intake and output, because these data provide information regarding hydration and the nutritional status of the client. The client's weight would be obtained and the baseline value compared with previous and subsequent values. Additionally, the nurse would instruct the client in how to accurately check and monitor her weight. Laboratory data may need to be evaluated; increased hemoglobin and hematocrit values may occur as a result of dehydration. Encouraging the client to verbalize her feelings about the diagnosis is a component of the plan of care but is not the first intervention during physical assessment.

A nurse is assigned to care for a client with a closed chest drainage system that was inserted 1 day ago after the client sustained a stab wound to the chest.

Assessing the patency and function of the chest tube. Checking the client's vital signs. Assessing the client's level of discomfort. Asking the client to cough and deep-breathe. The first action the nurse needs to perform is to assess the chest tube's patency and function, because a properly functioning chest drainage system promotes adequate drainage of blood and air. After this assessment, the nurse would check the client's vital signs, including pulse oximetry. The nurse would determine the client's level of discomfort, then provide appropriate pain relief measures, because improving the client's level of comfort will facilitate more effective coughing and deep-breathing efforts. Finally, the nurse would encourage the client to cough and deep-breathe.

A client is complaining of chest pain, and the nurse notes that the client's skin is cool and clammy. The client is receiving oxygen at a rate of 2 L/min, and the pulse oximetry reading is 84%. Which action should the nurse take first?

Increasing the oxygen to 3L/min Pulse oximetry identifies hemoglobin saturation. A pulse oximetry reading can alert the nurse to desaturation before clinical signs occur. Ideal pulse oximetry values range from 90% to 100%. A range of 85% to 89% is acceptable in certain chronic disease conditions. When the value is below 85%, the body's tissues have a difficult time becoming oxygenated. Therefore the nurse would increase the oxygen to 3 L/min. Although the client is complaining of chest pain, there is no information to indicate that the client is experiencing chest pain that is cardiac in origin, so administering nitroglycerin as the first action is incorrect. Taking the client's vital signs and obtaining an ABG specimen will provide additional data, but in this situation an intervention is needed first.

A client who has just undergone abdominal surgery calls the nurse and states, "I feel as if I just split open." The nurse checks the abdominal incision and finds wound evisceration. The nurse immediately:

Contacts the health care provider. Wound evisceration is the total separation of a surgical incision or wound with extrusion of the internal organs or viscera through the open wound. When evisceration occurs, the nurse immediately calls for help and has the health care provider notified. The nurse stays with the client and positions the client with the hips and knees bent. The nurse then covers the abdominal wound with a sterile dressing moistened with sterile saline solution. The nurse would then take the client's vital signs and document the occurrence. Since this is a surgical emergency, the operating room would be notified but this would not be done until directed to do so by the surgeon.

A registered nurse (RN) on the 7 a.m.-3 p.m. shift is planning client assignments for the day. Which clients would be appropriate for the RN to assign to the licensed practical nurse (LPN)?

A client who had a mastectomy 2 days ago. A client with type 1 diabetes mellitus who has a foot ulcer. A client with left-sided weakness who will need assistance with personal care. When a nurse delegates aspects of a client's care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. The client with COPD who was admitted during the night will need close monitoring of the respiratory status. An LPN may not administer most high-risk intravenous medications, including heparin. The client who has had a mastectomy and the client with a foot ulcer will likely require dressing changes, an activity that is within the scope of practice of the LPN. The client with left-side weakness requiring personal care assistance could also be assigned to the LPN.

A registered nurse (RN) is planning the client assignments for the day. To which nurse does the RN appropriately assign care of a woman undergoing brachytherapy with a sealed radiation source for cervical cancer?

A nurse who has worked with clients undergoing brachytherapy in the past. Brachytherapy involves the use of radioactive isotopes in solid form or within body fluids. Because the radiation source is within the client, the client emits radiation for some time and may pose a hazard to others. A pregnant nurse should not care for a client undergoing brachytherapy. The time any nurse is exposed to such radiation sources should be limited to 30 minutes of direct care per 8-hour shift, so a nurse should not be assigned to care for more than one client undergoing brachytherapy. It is most appropriate to assign a nurse who is familiar with the care of a client with brachytherapy rather than to assign a nurse who is not.

Inner maxillary fixation (IMF) is performed on a client who sustained a mandibular fracture in a motor vehicle crash. During an assessment, the client begins to vomit. The nurse suctions the client but is unsuccessful, and the client exhibits signs of hypoxia. The nurse immediately:

Cuts the mouth wires. IMF is a common means of securing a mandibular fracture. The bones are realigned and then wired in place with the bite closed. After surgery, the client is at risk for aspiration if he or she vomits because of the impossibility of opening the jaws to allow ejection of the emesis. If vomiting occurs, the nurse would attempt to suction the client. If suctioning is unsuccessful, the wires are cut. Wire cutters are kept with the client at all times in readiness for this emergency. Antiemetics may be prescribed to prevent nausea and subsequent vomiting; however, this is not the immediate action if the client is vomiting. Placing the client in a supine position increases the risk of aspiration. The client is placed in an upright position and turned to the side. There is no helpful reason to contact the anesthesiologist.

A nurse is monitoring a client with preeclampsia who is receiving intravenous magnesium sulfate to prevent seizures. The nurse notes that the client's respiratory rate is 10 breaths/min. On the basis of this finding, the nurse first:

Discontinues the magnesium sulfate. A respiratory rate slower than 12 breaths/min is a sign of magnesium toxicity.Other signs include the absence of deep tendon reflexes, altered sensorium, hypotension, and a serum magnesium level above the therapeutic range of 5 to 8 mg/dL (2.05 to 3.29 mmol/L). In this situation, the nurse would first discontinue the magnesium sulfate. The nurse would then take the client's vital signs and contact the health care provider health care providerThe most recent serum magnesium level may be checked; however, a current serum level would provide more useful data.

A child arrives at the emergency department experiencing anaphylaxis after being stung by a bee on the right arm. The nurse should first:

Place a tourniquet proximal to the site of the insect sting. Anaphylaxis is a severe immediate hypersensitivity reaction to an excessive release of chemical mediators. Treatment of anaphylaxis must be started immediately, because it may be only a matter of minutes before the child experiences shock. The nurse would immediately take steps to ensure an adequate airway, place a tourniquet just proximal to the site of the insect sting to help confine the allergen, administer epinephrine (medication of choice) as prescribed, administer oxygen, administer corticosteroids and antihistamines as prescribed, keep the child warm and lying flat or with the feet slightly elevated, and start an IV line.

A client is brought to the emergency department after a motor vehicle crash in which the client sustained a blunt chest injury when his chest struck the steering wheel. The client is complaining of sharp pain on inspiration and dyspnea. The nurse notes the absence of breath sounds on the affected side. The nurse would immediately:

Place the client in a Semi-Fowler position. The client is exhibiting signs of a closed pneumothorax. If a closed chest injury is suspected, the nurse must immediately place the client in a semi-Fowler position. Because this is a medical emergency, the nurse then notifies the health care provider. A chest x-ray, computed tomography, or ultrasonography would be used to confirm the diagnosis of pneumothorax. Because treatment involves thoracentesis and placement of a chest drainage system, the nurse then prepares a thoracentesis tray and chest drainage equipment.

A client is receiving an intravenous (IV) infusion of 1000 mL of normal saline solution at a rate of 125 mL/hr. The client suddenly complains of shortness of breath, and the nurse notes the presence of dependent edema and puffiness around the client's eyes. The nurse suspects circulatory overload and immediately:

Slows the IV rate Signs of circulatory overload include shortness of breath, cough, increased blood pressure, puffiness around the eyes, and edema in dependent areas. The client's neck veins may be engorged, and the nurse may hear moist breath sounds on auscultation of the lungs. If circulatory overload occurs, the nurse must immediately slow the IV rate and then notify the health care provider. The client would be placed in an upright position. The nurse would monitor the client's vital signs and administer oxygen and diuretics as prescribed.

A nurse is caring for a client after tonsillectomy and adenoidectomy. The nurse notes that the client has become restless and is swallowing frequently.

Inspecting the client's throat. Checking the client's vital signs. Notifying the surgeon. Maintaining NPO status. Bleeding is a potential complication after tonsillectomy and adenoidectomy. If the client becomes restless and is swallowing frequently, the nurse should suspect bleeding. The nurse would first inspect the throat for the presence of bleeding and then check the client's vital signs for indications of hypovolemia. The surgeon would be notified. Because recauterization is the treatment of choice when bleeding is uncontrolled, the client would be maintained on nothing-by-mouth (NPO) status in anticipation of a return to surgery.

A nurse is performing closed suctioning through a tracheostomy for a ventilator-dependent client. During the procedure, the alarm on the cardiac monitor sounds and the nurse notes severe bradycardia. The nurse stops suctioning the client and immediately:

Oxygenates the client manually with 100% oxygen. Suctioning is associated with several complications, including hypoxia, tissue (mucosal) trauma, infection, vagal stimulation, and bronchospasm. Vagal stimulation may result in severe bradycardia, hypotension, heart block, ventricular tachycardia, or asystole. If vagal stimulation occurs, the nurse stops suctioning immediately and oxygenates the client manually with 100% oxygen. Contacting the respiratory therapist will delay the required and immediate intervention. Although regular checks of the ventilator connections are the standard of care for a client undergoing mechanical ventilation, doing so will not alleviate the client's problem in this situation. An increase in PEEP is not indicated at this time.

A nurse is caring for a client with a diagnosis of endocarditis when the client suddenly begins to experience chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism.

Placing a nasal oxygen cannula on the client. Notifying the health care provider. Ensuring that the IV line is patent. Preparing an IV heparin sodium infusion. Preparing the client for a CT scan. Pulmonary embolism is a life-threatening emergency. Stabilizing the cardiopulmonary system is the first priority. Nasal oxygen is administered immediately to relieve hypoxemia, respiratory distress, and central cyanosis. The health care provider is notified. Because IV infusion lines are needed to administer fluids to treat the hypotension and to administer medications, the nurse ensures that the client has patent IV lines. Anticipating that IV anticoagulant therapy will be started, the nurse next prepares an administration set. Finally, because a CT scan or other diagnostic test may be performed to confirm the diagnosis, client preparations for testing are begun.

A nurse is preparing to care for a child being admitted to the hospital with infectious gastroenteritis. The priority nursing intervention is:

Starting an IV line as prescribed. Infectious gastroenteritis is caused by a variety of communicable viruses, bacteria, and parasites capable of causing serious diarrhea, massive fluid and electrolyte loss, sepsis, and death. The priority therapy in a child with infectious gastroenteritis is the replacement of water and correction of acid-base or fluid and electrolyte disturbances with the use of IV fluids or oral electrolyte-replacement preparations. A stool culture and antimicrobial drugs may be prescribed, but these are not the priority interventions. Instructions to the parents may be necessary but are not the priority on admission of the child to the hospital.