Chapter 14 - Prioritization, Delegation, and Assignment

A 24-year-old patient with diabetes insipidus makes all of these statements when the nurse is preparing the patient for discharge from the hospital. Which statement indicates to the nurse that the patient needs additional teaching? •"I will drink fluids equal to the amount of my urine output." •"I will weigh myself every day using the same scale." •"I will wear my medical alert bracelet at all times." •"I will gradually wean myself off the vasopressin."

•"I will gradually wean myself off the vasopressin." •A patient with permanent diabetes insipidus requires lifelong vasopressin therapy. All of the other statements are appropriate to the home care of this patient.

The LPN/LVN who is assigned to care for a patient with Cushing disease asks the RN why the patient has bruising and petechiae across her abdomen. What is the RN's *best* response? •"Patients with Cushing disease often have bleeding disorders." •"Patients with Cushing disease have very fragile capillaries." •"Please ask the patient if she slipped or fell during the night." •"Thin and delicate skin can result in development of bruising."

•"Patients with Cushing disease have very fragile capillaries." •A key cardiovascular feature seen in patients with Cushing disease is capillary fragility, which results in bruising and petechiae. Bleeding disorders are not a sign of Cushing disease, and although these patients have delicate skin, this is not the cause of the bruising. The nurse may want to investigate whether the patient fell, but these patients have bruising and petechiae without falls.

As the shift begins, the nurse is assigned to care for the following patients. Which patient should the nurse assess *first*? •A 38-year-old patient with Graves disease and a heart rate of 94 beats/min •A 63-year-old patient with type 2 diabetes and fingerstick glucose level of 137 mg/dL (7.6 mmol/L) •A 58-year-old patient with hypothyroidism and a heart rate of 48 beats/min •A 49-year-old patient with Cushing disease and dependent edema rated as + 1

•A 58-year-old patient with hypothyroidism and a heart rate of 48 beats/min •Although patients with hypothyroidism often have cardiac problems that include bradycardia, a heart rate of 48 beats/min may have significant implications for cardiac output and hemodynamic stability. Patients with Graves disease usually have a rapid heart rate, but 94 beats/min is within normal limits. The patient with diabetes may need sliding-scale insulin dosing. This is important but not urgent. Patients with Cushing disease frequently have dependent edema.

The nurse is caring for the following patients with endocrine disorders. Which patient must the nurse assess *first*? •A 21-year-old patient with diabetes insipidus whose urine output overnight was 2000 mL •A 55-year-old patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who is demanding that the unlicensed assistive personnel refill his water pitcher •A 65-year-old patient with Addison disease whose morning potassium level is 6.2 mEq/L (6.2 mmol/L) •A 48-year-old patient with Cushing disease with a weight gain of 1.5 lb (0.7 kg) over the past 4 days

•A 65-year-old patient with Addison disease whose morning potassium level is 6.2 mEq/L (6.2 mmol/L) •This patient's potassium level is very high, placing the patient at risk for cardiac dysrhythmias that could be life threatening. The other patients also need to be seen but are not as urgent.

Which patient should the charge nurse assign to the care of an LPN/LVN, under the supervision of the RN team leader? •A 51-year-old patient who has just undergone bilateral adrenalectomy •A 83-year-old patient with type 2 diabetes and chronic obstructive pulmonary disease •A 38-year-old patient with myocardial infarction preparing for discharge •A 72-year-old patient with mental status changes admitted from a long-term care facility

•A 83-year-old patient with type 2 diabetes and chronic obstructive pulmonary disease •The 83-year-old has no complicating factors at the moment. Providing care for patients in stable and uncomplicated condition falls within the LPN/LVN's educational preparation and scope of practice, with the care always being provided under the supervision and direction of an RN. The RN should assess the patient who has just undergone surgery and the newly admitted patient. The patient who is preparing for discharge after myocardial infarction may need some complex teaching.

The nurse is instructing a senior nursing student on the techniques for palpation of the thyroid gland. What precaution would the nurse be sure to include when instructing the student about thyroid palpation? •Always stand to the side of the patient •Instruct the patient not to swallow •Palpate using one hand and then the other •Always palpate the thyroid gland gently

•Always palpate the thyroid gland gently •The thyroid gland should always be palpated gently because vigorous palpation can stimulate a thyroid storm in a patient who may have hyperthyroidism. The student nurse should stand either behind or in front of the patient and use both hands to palpate the thyroid. Having the patient swallow can help with locating the thyroid gland.

Which actions should the nurse assign to the experienced LPN/LVN for the care of a patient with hypothyroidism? *Select all that apply.* •Assessing and recording the rate and depth of respirations •Auscultating lung sounds every 4 hours •Creating an individualized nursing care plan for the patient •Administering sedation medications every 6 hours •Checking blood pressure, heart rate, and respirations every 4 hours •Reminding the patient to report any episodes of chest pain or discomfort

•Assessing and recording the rate and depth of respirations •Auscultating lung sounds every 4 hours •Checking blood pressure, heart rate, and respirations every 4 hours •Reminding the patient to report any episodes of chest pain or discomfort •Assessment, auscultation, and reminding patients about information that has been taught to them are within the scope of practice of the LPN/LVN. The LPN/LVN could be assigned to check the patient's vital signs, and this is certainly within the scope of practice. Checking vital signs could also be delegated to the unlicensed assistive personnel. Creating nursing care plans falls within the scope of practice of the RN. The use of sedation is discouraged for patients with hypothyroidism because it may make respiratory problems more difficult. If sedation is used, the dosage is reduced, and it is not given around the clock.

The nurse is providing care for a patient who underwent thyroidectomy 2 days ago. Which laboratory value requires close monitoring by the nurse? •Calcium level •Sodium level •Potassium level •White blood cell count

•Calcium level •The parathyroid glands are located on the back of the thyroid gland. The parathyroids are important in maintaining calcium and phosphorus balance. The nurse should be attentive to all patient laboratory values, but calcium and phosphorus levels are especially important to monitor after thyroidectomy because abnormal values could be the result of removal of the parathyroid glands during the procedure.

Assessment findings for a patient with Cushing disease include all of the following. For which finding would the nurse notify the health care provider (HCP) *immediately*? •Purple striae present on the abdomen and thighs •Weight gain of 1 lb (0.5 kg) since the previous day •Dependent edema rated as + 1 in the ankles and calves •Crackles bilaterally in the lower lobes of the lungs

•Crackles bilaterally in the lower lobes of the lungs •The presence of crackles in the patient's lungs indicates excess fluid volume caused by excess water and sodium reabsorption and may be a symptom of pulmonary edema, which must be treated rapidly. Striae (stretch marks), weight gain, and dependent edema are common findings in patients with Cushing disease. These findings should be monitored but do not require urgent action.

When providing care for a patient with Addison disease, the nurse should be alert for which laboratory value change? •Decreased hematocrit •Increased sodium level •Decreased potassium level •Decreased calcium level

•Decreased hematocrit •A patient with Addison disease is at risk for anemia. The nurse should expect this patient's sodium level to decrease and potassium and calcium levels to increase.

The nurse is caring for a 25-year-old patient admitted to the acute care unit with an extra strong thirst, and dilute, excessive straw-colored urine output (up to 15 L/day). What does the nurse suspect? •Type 2 diabetes •Diabetes insipidus (DI) •Cushing disease •Addison disease

•Diabetes insipidus (DI) •DI is a disorder of the posterior pituitary gland in which water loss is caused by either an antidiuretic hormone (ADH) deficiency or an inability of the kidneys to respond to ADH. The result of DI is the excretion of large volumes of dilute urine because the distal kidney tubules and collecting ducts do not reabsorb water; this leads to polyuria. Dehydration from massive water loss increases plasma osmolarity, which stimulates the sensation of thirst. Thirst promotes increased fluid intake and aids in maintaining hydration.

The RN is supervising a senior student nurse who is caring for a fresh postoperative patient who had a hypophysectomy. The RN observes the student nurse perform all of these actions. For which action must the RN intervene? •Assess for changes in vision or mental status •Keep the head of the bed elevated •Remind the patient to perform deep breathing every hour while awake •Encourage the patient to cough vigorously

•Encourage the patient to cough vigorously •After hypophysectomy, the nurse should monitor the patient's neurologic response and document any changes in vision or mental status, altered level of consciousness, or decreased strength of the extremities. The head of the bed should be kept elevated. Patients should be reminded to perform deep-breathing exercises hourly while awake to prevent pulmonary problems. However, the patient should be taught to avoid coughing early after surgery because it increases pressure in the incision area and may lead to a cerebrospinal fluid (CSF) leak.

A patient with adrenal insufficiency is to be discharged and will take prednisone 10 mg orally each day. Which instruction would the nurse be sure to teach the patient? •Excessive weight gain or swelling should be reported to the health care provider •Changing positions rapidly may cause hypotension and dizziness •A diet with foods low in sodium may be beneficial to prevent side effects •Signs of hypoglycemia may occur while taking this drug

•Excessive weight gain or swelling should be reported to the health care provider •Rapid weight gain and edema are signs of excessive drug therapy, and the dosage of the drug would need to be adjusted. Hypertension, hyponatremia, hyperkalemia, and hyperglycemia are common in patients with adrenal hypofunction.

A patient is admitted to the medical unit with possible Graves disease (hyperthyroidism). Which assessment finding by the nurse supports this diagnosis? •Periorbital edema •Bradycardia •Exophthalmos •Hoarse voice

•Exophthalmos •Exophthalmos (abnormal protrusion of the eyes) is characteristic of patients with hyperthyroidism caused by Graves disease. Periorbital edema, bradycardia, and a hoarse voice are all characteristics of patients with hypothyroidism.

Two unlicensed assistive personnel (UAP) are assisting a patient with Cushing disease to move up in bed. Which action by the UAPs requires the nurse's *immediate* intervention? •Positioning themselves on opposite sides of the patient's bed •Grasping under the patient's arms to pull him up in bed •Lowering the side rails of the patient's bed before moving him •Removing the pillow before moving the patient up in bed

•Grasping under the patient's arms to pull him up in bed •Patients with Cushing disease usually have paper-thin skin that is easily injured. The UAPs should use a lift or a draw sheet to carefully move the patient and prevent injury to the skin. All of the other actions are appropriate to moving this patient up in bed.

The nurse admits a patient whose assessment reveals prominent brow ridge, large hands and feet, and large lips and nose. Which pituitary hormone does the nurse suspect is elevated? •Thyroid-stimulating hormone •Growth hormone •Adrenocorticotropic hormone •Vasopressin antidiuretic hormone

•Growth hormone •These assessment findings are classical initial manifestations for growth hormone excess.

The nurse is orienting a new graduate RN who is providing care for a postoperative patient after a thyroidectomy. The new graduate assesses the patient and notes laryngeal stridor with a pulse oximetry measure of 89%. What is the *priority* action for the nurse and new graduate? •Immediately notify the Rapid Response Team (RRT) •Apply oxygen by face mask •Prepare to suction the patient •Assess for numbness and tingling around the mouth

•Immediately notify the Rapid Response Team (RRT) •The first priority is to monitor the patient after surgery to identify symptoms of obstruction (stridor, dyspnea, falling oxygen saturation, inability to swallow, drooling) after thyroid surgery. If any are present, respond by immediately notifying the RRT. If the airway is obstructed, oxygen therapy will not be helpful, and the patient may need airway management such as intubation. For this reason, the RRT needs to be activated first. Emergency tracheostomy equipment, oxygen, and suctioning equipment should already be in the patient's room and have been checked to be sure that it is in working order.

The nurse is providing care for a male patient with hypogonadotropin who is receiving sex steroid replacement therapy with testosterone. Which changes indicate to the nurse that therapy is successful? *Select all that apply.* •Decreased facial hair •Increased libido •Decreased bone size •Increased muscle mass •Increased axillary hair growth •Increased breast tissue

•Increased libido •Increased axillary hair growth •Increased breast tissue •Therapy for gonadotropin deficiency begins with high-dose testosterone and is continued until virilization (presence of male secondary sex characteristics) is achieved, with responses that include increases in penis size, libido, muscle mass, bone size, and bone strength. Chest, facial, pubic, and axillary hair growth also increase. Patients usually report improved body image after therapy is initiated. Side effects of therapy include gynecomastia (male breast tissue development), acne, baldness, and prostate enlargement.

The nurse is preparing a care plan for a patient with Cushing disease. Which abnormal laboratory values would the nurse expect? *Select all that apply.* •Increased serum calcium level •Increased salivary cortisol level •Increased urinary cortisol level •Decreased serum glucose level •Decreased sodium level •Increased serum cortisol level

•Increased salivary cortisol level •Increased urinary cortisol level •Increased serum cortisol level •A patient with Cushing disease experiences increased levels of serum, urinary, and salivary cortisol. Other laboratory findings may include increased blood glucose level, decreased lymphocyte count, increased sodium level, and decreased serum calcium level.

The nurse assesses a newly admitted patient with a diagnosis of hyperthyroidism (see figure). How would the nurse *best* document the finding in this patient? •Bilateral exophthalmos •Large visible goiter •Myxedema •Moon face

•Large visible goiter •A patient with hyperthyroidism may have an enlarged thyroid gland (goiter) that can be 4 times the size of a normal gland. Exophthalmos refers to wide-eyed, startled look resulting from edema in the extraocular muscled and increased fatty tissue behind the eye that pushes the eye forward. Myxedema occurs often in patients with hypothyroidism, and moon face is a common characteristic of Cushing disease.

The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which patient care actions should the nurse delegate to the experienced unlicensed assistive personnel? *Select all that apply.* •Monitor and record strict intake and output •Provide the patient with ice chips when requested •Remind the patient about his or her fluid restriction •Weigh the patient every morning using the same scale •Report a weight gain of 2.2 lb (1 kg) to the nurse •Provide mouth care allowing the patient to swallow the rinses

•Monitor and record strict intake and output •Remind the patient about his or her fluid restriction •Weigh the patient every morning using the same scale •Report a weight gain of 2.2 lb (1 kg) to the nurse

A patient with pheochromocytoma underwent surgery to remove his adrenal glands. Which nursing intervention should the nurse delegate to an unlicensed assistive personnel (UAP)? •Revising the nursing care plan to include strategies to provide a calm and restful environment postoperatively •Instructing the patient to avoid smoking and drinking caffeine-containing beverages •Assessing the patient's skin and mucous membranes for signs of adequate hydration •Monitoring lying and standing blood pressure every 4 hours with a cuff placed on the same arm

•Monitoring lying and standing blood pressure every 4 hours with a cuff placed on the same arm •Monitoring vital signs is within the education and scope of practice for UAPs. The nurse should be sure to instruct the UAP that blood pressure measurements are to be taken with the cuff on the same arm each time and instructed to record and inform the RN of the results. Revising the care plan and instructing and assessing patients are beyond the scope of UAPs and fall within the purview of licensed nurses.

For a patient with hyperthyroidism, which task should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? •Instructing the patient to report any occurrence of palpitations, dyspnea, vertigo, or chest pain •Monitoring the apical pulse, blood pressure, and temperature every 4 hours •Drawing blood to measure levels of thyroid-stimulating hormone, triiodothyronine, and thyroxine •Teaching the patient about side effects of the drug propylthiouracil

•Monitoring the apical pulse, blood pressure, and temperature every 4 hours •Monitoring vital signs and recording their values are within the education and scope of practice of UAPs. An experienced UAP should have been taught how to monitor the apical pulse. However, a nurse should observe the UAP to be sure that the UAP has mastered this skill. Instructing and teaching patients, as well as performing venipuncture to obtain laboratory samples, are more suited to the education and scope of practice of licensed nurses. In some facilities, an experienced UAP may perform venipuncture, but only after special training.

The LPN/LVN is assigned to provide care for a patient with pheochromocytoma. Which physical assessment technique should the RN instruct the LPN/LVN to avoid? •Listening for abdominal bowel sounds in all four quadrants •Palpating the abdomen in all four quadrants •Checking the blood pressure every hour •Assessing the mucous membranes for hydration status

•Palpating the abdomen in all four quadrants •Palpating the abdomen can cause the sudden release of catecholamines and severe hypertension. All of the other assessments are appropriate for the LPN/LVN assigned to care for this patient.

A female patient is admitted with a diagnosis of primary hypofunction of the adrenal glands. Which nursing assessment finding supports this diagnosis? •Patchy areas of pigment loss over the face •Decreased muscle strength •Greatly increased urine output •Scalp alopecia

•Patchy areas of pigment loss over the face •Vitiligo, or patchy areas of pigment loss with increased pigmentation at the edges, is seen with primary hypofunction of the adrenal glands and is caused by autoimmune destruction of melanocytes in the skin. The other findings are signs of pituitary hypofunction.

The nurse is caring for a patient who has just undergone hypophysectomy for hyperpituitarism. Which postoperative finding requires *immediate* intervention? •Presence of glucose in the nasal drainage •Presence of nasal packing in the nares •Urine output of 40 to 50 mL/hr •Patient reports of thirst

•Presence of glucose in the nasal drainage •The presence of glucose in nasal drainage indicates that the fluid is cerebrospinal fluid (CSF) and suggests a CSF leak. Packing is normally inserted in the nares after the surgical incision is closed. Urine output of 40 to 50 mL/hr is adequate, and patients may experience thirst postoperatively. When patients are thirsty, nursing staff should encourage fluid intake.

Which change in vital signs would the nurse instruct the unlicensed assistive personnel to report *immediately* for a patient with hyperthyroidism? •Rapid heart rate •Decreased systolic blood pressure •Increased respiratory rate •Decreased oral temperature

•Rapid heart rate •The cardiac problems associated with hyperthyroidism include tachycardia, increased systolic blood pressure, and decreased diastolic blood pressure. Patients with hyperthyroidism also may have increased body temperature related to increased metabolic rate. Respiratory changes are usually not symptomatic of this condition.

Which prescribed order for a patient with diabetes insipidus (DI) would the nurse be sure to question? •Monitor and record accurate intake and output •Check urine specific gravity •Restrict fluids for 6 hours •Weigh the patient every morning

•Restrict fluids for 6 hours •Ensure that no patient suspected of having DI is deprived of fluids for more than 4 hours because reduced urine output and severe dehydration can result. Interventions for DI include accurately measuring fluid intake and output, checking urine specific gravity, and recording the patient's weight daily.

The nurse is preparing to discharge a patient with hyperpituitarism caused by a benign pituitary tumor, who is prescribed the drug bromocriptine. Which key points would the nurse teach the patient about this drug? *Select all that apply.* •Take this drug with a meal or snack to avoid gastrointestinal (GI) symptoms •Side effects of bromocriptine include severe fatigue and reflux after meals •Seek medical care if you experience chest pain or dizziness while taking this drug •If the drug causes headaches, you can take over-the-counter acetaminophen •Treatment starts with a high dose, which is gradually lowered •The purpose of bromocriptine is to shrink your pituitary to normal size

•Take this drug with a meal or snack to avoid gastrointestinal (GI) symptoms •Seek medical care if you experience chest pain or dizziness while taking this drug •If the drug causes headaches, you can take over-the-counter acetaminophen •The purpose of bromocriptine is to shrink your pituitary to normal size •Bromocriptine is a dopamine agonist drug that stimulates dopamine receptors in the brain and inhibits the release of growth hormone and prolactin. In most cases, small tumors decrease until the pituitary gland is of normal size. Side effects of bromocriptine include orthostatic (postural) hypotension, headaches, nausea, abdominal cramps, and constipation. Give bromocriptine with a meal or a snack to reduce GI side effects. Treatment starts with a low dose and is gradually increased until the desired level is reached. Patients taking bromocriptine should be taught to seek medical care immediately if chest pain, dizziness, or watery nasal discharge occurs because of the possibility of serious side effects, including cardiac dysrhythmias, coronary artery spasms, and cerebrospinal fluid leakage. Also, if the patient is a female of childbearing age who becomes pregnant, the drug should be stopped.

The nurse is caring for a patient with hyperthyroidism who had a partial thyroidectomy yesterday. Which change in assessment would the nurse report to the health care provider *immediately*? •Temperature elevation to 100.2°F (37.9°C) •Heart rate increase from 64 to 76 beats/min •Respiratory rate decrease from 26 to 16 breaths/min •Pulse oximetry reading of 92%

•Temperature elevation to 100.2°F (37.9°C) •When caring for a patient with hyperthyroidism, even after a partial thyroidectomy, a temperature elevation of 1°F must be reported immediately because it may indicate an impending thyroid crisis. The other changes should be monitored, but none is urgent.

Which actions prescribed by the health care provider for the patient with Addison disease should the nurse delegate to the experienced unlicensed assistive personnel (UAP)? *Select all that apply.* •Weigh the patient every morning •Obtain fingerstick glucose before each meal and at bedtime •Check vital signs every 2 hours •Monitor for cardiac dysrhythmias •Administer oral prednisone 10 mg every morning •Record intake and output

•Weigh the patient every morning •Obtain fingerstick glucose before each meal and at bedtime •Check vital signs every 2 hours •Record intake and output •Weighing patients, recording intake and output, and checking vital signs are all within the scope of practice for a UAP. An experienced UAP would have been trained to perform fingerstick glucose monitoring. The nurse should make sure that the UAP has mastered this skill and then instruct the UAP to record and inform him or her about the results. Administering medications and monitoring for cardiac dysrhythmias are within the scope of practice of licensed nurses.

The patient with hyperparathyroidism who is not a candidate for surgery asks the nurse why she is receiving IV normal saline and IV furosemide. What is the nurse's *best* response? •"This therapy is to protect your kidney function." •"You are receiving these therapies to prevent edema formation." •"Diuretic and hydration therapies are used to reduce your serum calcium." •"These therapies may help to improve your candidacy for surgery."

•"Diuretic and hydration therapies are used to reduce your serum calcium." •Diuretics and hydration help reduce serum calcium for patients with hyperparathyroidism who are not surgery candidates. Furosemide increases kidney excretion of calcium when combined with IV saline in large volumes.

A patient is hospitalized with adrenocortical insufficiency. Which nursing activity should the nurse delegate to unlicensed assistive personnel (UAP)? •Reminding the patient to change positions slowly •Assessing the patient for muscle weakness •Teaching the patient how to collect a 24-hour urine sample •Revising the patient's nursing plan of care

•Reminding the patient to change positions slowly •Patients with hypofunction of the adrenal gland often have hypotension and should be instructed to change positions slowly. After a patient has been so instructed, it is appropriate for the UAP to remind the patient of the instructions. Assessing, teaching, and planning nursing care require more education and should be done by licensed nurses.