Prioritization and Delegation - ML8

The nurse is caring for an 8-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child?

diluting the chemicals Diluting the chemical is the priority. It will help remove the chemical and stop the burning process. The remaining treatments are initiated after dilution.

The nurse can assign an unlicensed assistive personnel (UAP) to which client? A client who:

had a newly created urinary diversion 3 days ago. When delegating care, the nurse should consider the skill level of the UAP and the needs of the client. The UAP is able to assist with activities of daily living and basic care activities. The client who had surgery to establish a urinary diversion 3 days ago is the most stable of the clients and can be assigned to the UAP for basic care. The client with cranial surgery is 1 day postoperative and will require frequent neurological assessment; this client should be assigned to a registered nurse. The client with a radiation seeding is on radiation precautions and should be assigned to a registered nurse. The client showing signs of progressive confusion is the least stable and requires direct care by a nurse.

The nurse is assessing a client 22 hours after a cesarean birth. Which assessment finding would require immediate action by the nurse?

heart rate of 132 beats/min and blood pressure of 84/60 mm Hg

The nurse is caring for a school-aged client with sickle cell anemia. The nurse would prioritize preventing what physical state to best reduce the risk for activating sickling of red blood cells in the client?

hypoxia The most critical need of a client in sickle cell crisis is to provide adequate oxygenation, hydration, and pain management until the crisis passes. States of hypoxia are most likely to trigger sickling. Hypoxia can be caused by increased oxygen consumption during stress, pain, or fever but because these conditions are only potential contributors to hypoxia, focusing on the broader goal of preventing hypoxia in general is the better nursing priority. Fluid volume deficit (dehydration) is also a contributor to sickling but fluid volume excess is not. By thinking about care in a more conceptual way, the nurse is better able to address all potential causes of hypoxia as an important trigger for sickling.

What is the nurse's priority when caring for a 10-month-old infant with meningitis?

maintaining an adequate airway Maintaining an adequate airway is always a top priority. Maintaining fluid and electrolyte balance and controlling seizures and hyperthermia are all important, but not as important as an adequate airway.

A nurse is caring for a client recovering from cocaine use. Which is the priority intervention for this client?

suicide precautions Clients recovering from cocaine use are prone to post-coke depression, and have a likelihood of becoming suicidal if they can't take the drug. Frequent orientation and skin care are routine nursing interventions but aren't the most immediate considerations for this client. Nutrition consultation isn't the most pressing intervention for this client.

A client experiencing alcohol withdrawal reports being upset about going through detoxification. Which goal is the priority for this client?

working with the nurse to remain safe The priority goal is for client safety. Symptoms of alcohol withdrawal syndrome can include delirium and seizures. Although drinking enough fluids, identifying personal strengths, and committing to a drug-free lifestyle are important goals, the nurse's priority at this time is to promote client safety.

A client with no history of cardiovascular disease comes to the ambulatory clinic with flulike symptoms and a report of chest pain. What question should the nurse ask this client first?

"How would you describe the pain?" Chest pain is assessed by using the standard pain assessment parameters such as characteristics, location, duration, intensity, precipitating factors, and associated symptoms. Beginning with a broader question allows the client to describe the experience with the pain, which directs the nurse on how to clarify this description. Asking if it radiates or increases with taking a deep breath are very specific questions and should be posed only after the client offers interpretation of the pain. The nurse does not offer medication until the pain assessment has been conducted.

A client is admitted with an eating disorder. Which client response should the nurse address first?

"I feel dizzy and light-headed when I get up." The priority intervention, by the nurse, would be to assess the client's vital signs to note any alterations. A client stating "My life is over if I gain weight" is an example of catastrophizing. Dental erosion and caries are commonly found in a client with an eating disorder. Muscle weakness is also commonly found in a client with an eating disorder.

Which client is most at risk for developing acute lymphocytic leukemia?

A 4-year-old white female Acute lymphocytic leukemia is most common in young children and in adults age 65 and older. It's also more common in whites than in blacks or Asians.

A nurse, working in a rural county's public health department, has been alerted that there is an outbreak of tuberculosis (TB) in the area. Which client is at highest risk for developing TB?

A 43-year-old homeless man with a history of alcoholism

The nurse is assigned four clients. Which client is at highest risk for impaired skin integrity?

A client having reconstructive breast surgery

The nurse is making assignments for the next shift. Which client can be assigned to a licensed practical nurse/licensed vocational nurse (LPN/LVN)? Select all that apply.

A client who needs assistance with colostomy irrigation A client who is receiving glargine subcutaneously

A nurse has been assigned to four clients. Which client should the nurse see first?

A client with hemophilia who is receiving acetylsalicylic acid (ASA) for joint pain

The nurse is planning interventions for a client who is having an acute gout attack. What is the priority nursing intervention for this client?

Administer prescribed analgesics

A client with a pulmonary embolism is experiencing chest pain and apprehension. What is the nurse's priority intervention?

Administering ordered analgesic

A staff nurse receives a phone call and is told there is a bomb in a client's room. What is the nurse's priority action?

Ask the caller for details about the bomb placement. With imminent danger, it is important to determine as much information as possible, as quickly as possible. Transferring the call, or placing the caller on hold could result in a disconnection and loss of information. Clients may need to be evacuated.

A client who developed gestational diabetes mellitus during the pregnancy has just been admitted in the labor and delivery unit. What is the priority nursing action for this client?

Ask the client about her most recent blood glucose levels.

A 40-year-old client with schizophrenia lives in a rooming house. The client scratches vigorously and reports creatures eating at the skin. Which intervention should be done first?

Assess the physical problems.

A child with Wilms' tumor has had a kidney removed, and is now receiving chemotherapy. What priority information should the nurse share with this child's family at the time of discharge?

Avoid contact sports. Because the child has only one kidney, certain precautions are recommended to prevent injury to the remaining kidney. Fluid intake is essential for renal function, and should not be decreased. The child's sodium intake shouldn't be reduced. Avoiding other children is unnecessary, may make the child feel self-conscious, and may lead to regressive behavior.

The nurse is preparing to feed an infant diagnosed with pyloric stenosis prior to surgical repair. What is the nurse's most important intervention?

Burp the infant frequently. These infants usually swallow a lot of air from sucking on their hands and fingers because of their intense hunger. Burping frequently will reduce gastric distention, and increase the likelihood that the infant will retain the feeding. Feedings should be given slowly with the infant lying in a semi-upright position. Parental participation should be encouraged to the extent possible, but this will not increase the likelihood that the feeding will be retained. Record the type, amount, and character of the vomit, as well as its relation to the feeding. The amount of feeding volume lost is usually refed to the infant.

A physical therapist has instructed the nursing staff on how to perform range-of-motion (ROM) exercises for an infant with torticollis. The nurse is uncomfortable when the infant cries and grimaces during the exercises. What is the most important action for the nurse to take?

Call the physical therapist.

A school-age child with a dog bite is brought to the emergency department by the parents. What is the nurse's priority action?

Clean and irrigate the bite wounds.

The nurse is planning care for an infant with bronchiolitis who requires monitoring for dehydration. What is the most important intervention for the nurse to provide?

Daily weight Weight is a good indicator of hydration in infants. Accurate measurement of intake and output is essential. Weighing diapers is a way of measuring output only. Blood levels may be obtained daily or every other day. A urinalysis every eight hours is not necessary. Urine specific gravities are recommended but can be obtained with diaper changes.

A postpartum mother is concerned about a noted decrease in her breast milk production. Which response by the nurse best addresses this mother's concern?

Decrease supplemental feedings with formula.

A local chemical plant has had an environmental leak requiring the mass evacuation of its employees and neighbors in the surrounding area. The emergency room nurse is in the triage area when the first client is brought to the hospital. What should the nurse do first?

Determine what decontamination measures took place in the field before approaching the client.

The nurse is caring for a client with functional neurologic symptom disorder who has experienced pseudoseizures. What intervention is appropriate for the nurse to perform?

Encourage the client to discuss feelings about the pseudoseizures. Pseudoseizures or psychogenic nonepileptic seizures are considered a psychological symptom and are not related to electrical disturbance in the central nervous system as epileptic seizures are. However, they are a serious disorder and should not be minimized to the client by the nurse. Cognitive behavioral therapy is a primary intervention and requires open dialogue between the client and nurse so the client should be encouraged to verbalize feelings. Placebo administration is unethical, and the nurse should not participate in this intervention. While the nurse should remain calm and not draw excessive attention to the client during a pseudoseizure, the nurse should not ignore the client outright.

The nurse is preparing a client in labor for the administration of an epidural. What is the most important intervention by the nurse?

Give a fluid bolus of 500 ml. One of the major adverse effects of epidural administration is hypotension. Therefore, a 500-ml fluid bolus is usually administered to help prevent hypotension in the client who wishes to receive an epidural for pain relief. Eliciting maternal reflexes, inserting a Foley catheter, and administering I.V. pain medications are not necessary for the insertion of an epidural.

A 10-month-old child is found choking. The child is conscious but is not coughing or making other sounds. What is the nurse's priority intervention?

Give five back blows and five chest thrusts. Because this infant is not coughing or making sounds, the infant has a severe foreign body airway obstruction. Because the infant is still conscious, the nurse should immediately begin giving five back blows followed by five chest thrusts, in a repeated cycle, in an attempt to dislodge the object and open the airway. Abdominal thrusts should not be performed because they can damage an infant's liver. After the airway is open, the nurse should check for a foreign object and remove it with a finger sweep if it can be seen. A blind finger sweep should never be performed because it may push the object further into the airway. If the infant loses consciousness, the nurse should begin CPR.

A nurse is preparing a client for cardiac catheterization. What is the nurse's priority assessment?

Known allergies

A school-age client with a diagnosis of epilepsy is admitted to the pediatric unit of a local hospital for evaluation of anticonvulsant medications. As the nurse enters the client's room, the client begins to have a seizure. What is the priority nursing action?

Loosen any restrictive clothing.

An assessment of a client on the first day after a thoracotomy shows a temperature of 100° F (37.8° C); heart rate, 96 bpm; blood pressure, 136/86 mm Hg; and shallow respirations at 30 breaths/min, with rhonchi at the bases. The client is diaphoretic, anxious, and reports of incisional pain. Which nursing action is priority?

Medicate the client for pain as ordered. Although all the interventions are incorporated in this client's care plan, the priority is to relieve pain and make the client comfortable. This will relax the client, decrease the respirations, and make deep breathing and coughing more comfortable. In addition, this would give the client the energy and stamina to achieve the other objectives.

What is the nurse's priority action in caring for a client who has just had a liver biopsy?

Monitor vital signs. Internal bleeding is a potential complication following a liver biopsy. Elevated pulse and decreased blood pressure are indications that the client may be developing shock, which results in altered circulation. Physiologic needs take priority over psychological needs, Assessing feelings and teaching should be addressed after immediate needs. Pain is considered a psychological reaction unless the client is experiencing an acute episode that is causing physiologic response.

The nurse is monitoring a client, who is six hours post embolectomy, for an acute arterial occlusion of the left leg. When a Doppler ultrasound fails to detect a pedal pulse, the nurse notifies the surgeon who requests that the client be prepared for immediate surgery. The client refuses to consider additional surgery. What is the nurse's initial intervention?

Notify the provider immediately

A client who is at 35 weeks' gestation arrives at a labor and delivery unit leaking clear fluid from her vagina. What is the most appropriate nursing intervention?

Obtain a sterile speculum sample of the fluid for culture. A sterile speculum examination is performed to identify ruptured membranes. Confirmation is done with nitrazine paper and a positive ferning test. With premature rupture of membranes in a client under 37 weeks' gestation, cervical examinations are contraindicated to reduce the incidence of infection. Clean catch urine specimens, not catheterized specimens, would be appropriate to rule out infection. The client should ambulate only after a thorough nursing assessment and examination to determine the safety of the client and fetus.

A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. What would the nurse do first?

Perform a pelvic examination.

A child is admitted to the pediatric unit with an unknown mass in her lower left abdomen. Which is the nurse's priority action?

Place a "do not palpate abdomen" sign over the child's bed

A nurse is examining a client in active labor, who has had spontaneous rupture of the amniotic membrane, and notes a protruding umbilical cord. What is the priority nursing action?

Place the client in knee-chest position. A Trendelenburg or knee-chest position takes the weight of the fetus off the umbilical cord, allowing blood to flow. The cord should never be pushed back into the uterus, as this could damage the cord, obstruct the flow of blood through the cord to the fetus, or introduce infection into the uterus. The client should not be instructed to push, as she is only in active labor, and emergency surgery may be necessary. The cord should be wrapped in a sterile saline-soaked gauze.

A client displays signs associated with a possible ruptured aortic aneurysm. What is the priority nursing intervention?

Prepare the client for surgical intervention

The nurse is caring for a client admitted with Addisonian crisis. Which outcome is the priority?

Preventing irreversible shock A client in Addisonian crisis has an uncontrolled loss of sodium in the urine, and impaired mineralocorticoid function, which results in a loss of extracellular fluid, low blood volume, and possible irreversible shock. Preventing infection isn't an appropriate goal in this life-threatening situation. Relieving anxiety is appropriate after the client is stabilized. The client in Addisonian crisis is hypotensive, and blood pressure should be raised not lowered.

A nurse is planning care for a 14-year-old client following an appendectomy. What is the most important intervention?

Promote the development of an identity and independence.

Immediately after birth, a nurse assesses the neonate's respiratory effort as slow. The neonate is actively moving but grimaces in response to stimulation. The neonate's fingers and toes are bluish and the heart rate is 130 bpm. Which step should the nurse take next?

Provide oxygen and stimulate the baby to cry.

A client, who underwent femoral-popliteal (fem-pop) bypass surgery, is scheduled to return from the post-anesthesia care unit. Which staff member should receive this client?

Registered nurse with one year of experience

Which health education topic is the priority when teaching parents ways to prevent urinary tract infections (UTIs) in their children?

Teach parents to promote adequate fluid intake. Urinary stasis is a major cause of UTIs, and can be partially prevented by increasing fluid intake. Baths and hand hygiene are less significant factors in the development of UTIs. Urinary tract infections are increased in uncircumcised male infants under 1 year of age, but unaffected thereafter.

A client is admitted to a mental health unit. While assessing the client, the nurse finds the client exhibiting signs of hyperexcitability, increasing agitation, and distractibility. Based on this assessment, which nursing intervention has priority?

Use a quiet room for the client away from others.

A health care provider has placed a stat order for a urine specimen for culture and sensitivity. What is the best way for the nurse to delegate this task to an unlicensed assistive personnel?

We need to collect urine from the client in room 101 for a stat culture. Please tell me when you send it to the lab. This option not only delegates the task but also provides a checkpoint. To effectively delegate, you need to follow up on what someone else is doing. The other options don't provide for feedback, which is essential for communication and delegation.

The nurse is examining charts to identify clients at risk for developing multiple myeloma. Which client is most at risk?

a 60-year-old Black man Multiple myeloma is more common in middle-aged and older adult clients. The median age at diagnosis is 60 years. It is twice as common in Black clients as it is in White clients, and it occurs most often in Black men.

The nurse is reviewing the interventions listed in the plan of care for a child in vaso-occlusive crisis. Which intervention should the nurse implement first?

administering analgesics Pain management is a priority intervention when a client is in crisis. Analgesics are used to control pain. Hydration is essential to promote hemodilution and maintain electrolyte balance. Bed rest should be promoted to reduce oxygen utilization. Antibiotics will not be effective in resolving the vaso-occlusive crisis.

A 24-year-old client comes into the clinic reporting sudden-onset, right-sided chest pain and shortness of breath. While assessing the client, the nurse determines that the most important intervention is to:

auscultate the breath sounds. Because this client is short of breath, listening to breath sounds will allow the nurse to obtain information to support care decisions and report information that will help identify the problem. Breath sounds may be decreased, abnormal or absent when a client is short of breath. The client may need a chest X-ray and an ECG, but a health care provider must order these tests. Unless a cardiac source for the client's pain is identified, an echocardiogram won't be necessary.

A client at term arrives in the labor and delivery unit experiencing contractions every 4 minutes. After a brief assessment, the client is admitted, and an electronic fetal monitor is applied. Which assessment finding would be most concerning to the nurse?

blood pressure of 146/90 mm Hg A blood pressure of 146/90 mm Hg may indicate gestational hypertension. Over time, gestational hypertension reduces blood flow to the placenta and can cause intrauterine growth restriction, and other problems that reduce the fetus's ability to tolerate the stress of labor. A weight gain of 30 lb (13.6 kg) is within expected parameters for a healthy pregnancy. A woman over age 30 doesn't have a greater risk of complications if her general condition is healthy before pregnancy. Syphilis that has been treated does not pose an additional risk.