Chapter 8 - Prioritization, Delegation, and Assignment
A patient with severe iron deficiency anemia is to receive iron dextran complex 25 mg IV. The medication is diluted in 250 mL of normal saline and is to be infused over 6 hours. The nurse will infuse __________ mL/hr. (Round to 2 decimal points.)
• 41.67 mL/hr •To infuse 250 mL of solution during 6 hours, the nurse will need to infuse 41.67 mL/hr.
The home health nurse is obtaining a history for a patient who has deep vein thrombosis and is taking warfarin 2 mg/day. Which statement by the patient is the *best* indicator that additional teaching about warfarin may be needed? •"I have started to eat more healthy foods like green salads and fruit." •"The doctor said that it is important to avoid becoming constipated." •"Warfarin makes me feel a little nauseated unless I take it with food." •"I will need to have some blood testing done once or twice a week."
•"I have started to eat more healthy foods like green salads and fruit." •Patients taking warfarin are advised to avoid making sudden dietary changes because changing the oral intake of foods high in vitamin K (e.g., green leafy vegetables and some fruits) will have an impact on the effectiveness of the medication. The other statements suggest that further teaching may be indicated, but more assessment for teaching needs is required first.
A 67-year-old patient who is receiving chemotherapy for lung cancer is admitted to the hospital with thrombocytopenia. Which statement made by the patient when the nurse is obtaining the admission history is of *most* concern? •"I've noticed that I bruise more easily since the chemotherapy started." •"My bowel movements are soft and dark brown." •"I take ibuprofen every day because of my history of osteoarthritis." •"My appetite has decreased since the chemotherapy started."
•"I take ibuprofen every day because of my history of osteoarthritis." •Because nonsteroidal anti-inflammatory drugs (NSAIDs) will decrease platelet aggregation, patients with thrombocytopenia should not use ibuprofen routinely. Patient teaching about this should be included in the care plan. Bruising is consistent with the patient's admission problem of thrombocytopenia. Soft, dark brown stools indicate that there is no frank or occult blood in the bowel movements. Although the patient's decreased appetite requires further assessment by the nurse, this is a common complication of chemotherapy.
A 22-year-old patient with stage I Hodgkin disease is admitted to the oncology unit for radiation therapy. During the initial assessment, the patient tells the nurse, "Sometimes I'm afraid of dying." Which response is *most* appropriate at this time? •"Many individuals with this diagnosis have some fears." •"Perhaps you should ask the doctor about medication." •"Tell me a little bit more about your fear of dying." •"Most people with stage I Hodgkin disease survive."
•"Tell me a little bit more about your fear of dying." •More assessment about what the patient means is needed before any interventions can be planned or implemented. All of the other statements indicate an assumption that the patient is afraid of dying of Hodgkin disease, which may not be the case.
After the nurse receives the change-of-shift report, which patient should be assessed *first*? •A 20-year-old patient with possible acute myelogenous leukemia who has just arrived on the medical unit •A 38-year-old patient with aplastic anemia who needs teaching about decreasing infection risk before discharge •A 40-year-old patient with lymphedema who requests help in putting on compression stockings before getting out of bed •A 60-year-old patient with non-Hodgkin lymphoma who is refusing the prescribed chemotherapy regimen
•A 20-year-old patient with possible acute myelogenous leukemia who has just arrived on the medical unit •The newly admitted patient should be assessed first because the baseline assessment and plan of care need to be completed. The other patients also need assessments or interventions but do not need immediate nursing care.
A group of patients is assigned to an RN-LPN/LVN team. The LPN/LVN should be assigned to provide patient care and administer medications to which patient? •A 36-year-old patient with chronic kidney failure who will need a subcutaneous injection of epoetin alfa •A 39-year-old patient with hemophilia B who has been admitted to receive a blood transfusion •A 50-year-old patient with newly diagnosed polycythemia vera who will require phlebotomy •A 55-year-old patient with a history of stem cell transplantation who has a bone marrow aspiration scheduled
•A 36-year-old patient with chronic kidney failure who will need a subcutaneous injection of epoetin alfa •LPNs/LVNs should be assigned to care for stable patients. Subcutaneous administration of epoetin is within the LPN/LVN scope of practice. Blood transfusions should be administered by RNs because evaluation for and management of transfusion reactions require RN-level education and scope of practice. The other patients will require teaching about phlebotomy and bone marrow aspiration that should be implemented by the RN.
The charge nurse is making the daily assignments on the medical-surgical unit. Which patient is *best* assigned to a float RN who has come from the postanesthesia care unit (PACU)? •A 30-year-old patient with thalassemia major who has an order for subcutaneous infusion of deferoxamine •A 43-year-old patient with multiple myeloma who requires discharge teachingA 43-year-old patient with multiple myeloma who requires discharge teaching •A 52-year-old patient with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy •A 65-year-old patient with pernicious anemia who has just been admitted to the unit
•A 52-year-old patient with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy •A nurse who works in the postanesthesia care unit will be familiar with the monitoring needed for a patient who has just returned from a procedure such as a colonoscopy, which requires moderate sedation or monitored anesthesia care (conscious sedation). Care of the other patients requires staff with more experience with various types of hematologic disorders and would be better to assign to nursing personnel who regularly work on the medical-surgical unit.
After the nurse receives a change-of-shift report, which patient should be seen *first*? •A 26-year-old patient with thalassemia who has a hemoglobin level of 8 g/dL (80 g/L) and orders for a blood transfusion •A 44-year-old patient admitted 3 days previously for sickle cell crisis who is scheduled for a computed tomographic (CT) scan •A 50-year-old patient with stage IV non-Hodgkin lymphoma who is crying and saying, "I'm not ready to die" •A 69-year-old patient with chemotherapy-induced neutropenia who has an oral temperature of 100.1°F (37.8°C)
•A 69-year-old patient with chemotherapy-induced neutropenia who has an oral temperature of 100.1°F (37.8°C) •Any temperature elevation in a neutropenic patient may indicate the presence of a life-threatening infection, so actions such as drawing blood for culture and administering antibiotics should be initiated quickly. The other patients need to be assessed as soon as possible but are not critically ill.
When the nurse is assessing a patient with chronic kidney disease who is receiving epoetin alfa (erythropoietin) injections, which finding *most* indicates a need to talk with the health care provider (HCP) before giving the medication? •Hemoglobin level is 8.9 g/dL (89 g/L) •Blood pressure is 198/92 mm Hg •The patient does not like subcutaneous injections. •The patient has a history of myocardial infarction
•Blood pressure is 198/92 mm Hg •Epoetin alfa can cause hypertension, and blood pressure should be controlled before administering the medication. Because patients with chronic kidney disease have chronic anemia, a hemoglobin level of 8.9 g/dL (89 g/L) is not unusual. Although the nurse could ask the HCP about IV administration of the medication, subcutaneous administration requires a lower dose of the medication and is preferred. Epoetin alfa can cause angina or myocardial infarction, but the risk is highest when hemoglobin levels are greater than 11 g/dL (110 g/L).
A patient with Hodgkin lymphoma who is receiving radiation therapy to the groin area has skin redness and tenderness in the area being irradiated. Which nursing activity should the nurse delegate to the unlicensed assistive personnel (UAP) caring for the patient? •Checking the skin for signs of redness or peeling •Assisting the patient in choosing appropriate clothing •Explaining good skin care to the patient and family •Cleaning the skin over the area daily with a mild soap
•Cleaning the skin over the area daily with a mild soap •Skin care is included in UAP education and job description. Assessment and patient teaching are more complex tasks that should be delegated to RNs. Because the patient's clothes need to be carefully chosen to prevent irritation or damage to the skin, the RN should assist the patient with this.
A 32-year-old patient with sickle cell anemia is admitted to the hospital during a sickle cell crisis. Blood pressure is 104/62 mm Hg, oxygen saturation is 92%, and the patient reports pain at a level 8 (on a scale of 0 to 10). Which action prescribed by the health care provider will the nurse implement *first*? •Administer morphine sulfate 4 to 8 mg IV. •Give oxygen at 4 L/min per nasal cannula •Start an infusion of normal saline at 200 mL/hr •Apply warm packs to painful joints
•Give oxygen at 4 L/min per nasal cannula •National guidelines for sickle cell crisis indicate that oxygen should be administered if the oxygen saturation is less than 95%. Hypoxia and deoxygenation of the blood cells are the most common cause of sickling, so administration of oxygen is the priority intervention here. Pain control (including administration of morphine and application of warm packs to joints) and hydration are also important interventions for this patient and should be accomplished rapidly.
A patient with sickle cell disease is admitted with splenic sequestration. The blood pressure is 86/40 mm Hg, and heart rate is 124 beats/min. Which of these actions will the nurse take *first*? •Complete a head-to-toe assessment •Draw blood for type and cross-match •Infuse normal saline at 250 mL/hr •Ask the patient about vaccination history
•Infuse normal saline at 250 mL/hr •Because the patient is severely hypotensive, correction of hypovolemia caused by the splenic sequestration is the most urgent action. The other actions are appropriate because a complete assessment will be needed to plan care, a transfusion is likely to be needed, and vaccination history is pertinent for patients with sickle cell disease. However, infusion of saline is the priority need.
A patient with graft-versus-host disease after bone marrow transplantation is being cared for on the medical unit. Which nursing activity is *best* assigned to a travel RN? •Administering oral cyclosporine •Assessing the patient for signs of infection •Infusing 5% dextrose in 0.45% saline at 125 mL/hr •Educating the patient about ways to prevent infection
•Infusing 5% dextrose in 0.45% saline at 125 mL/hr •The infusion of IV fluids is a common intervention that can be implemented by RNs who do not have experience in caring for patients who are severely immunosuppressed. Administering cyclosporine, assessing for subtle indications of infection, and patient teaching are more complex tasks that should be done by RN staff members who have experience caring for immunosuppressed patients.
A patient with an absolute neutrophil count of 300/μL (0.3 × 109/L) is admitted to the oncology unit. Which staff member should the charge nurse assign to provide care for this patient, under the supervision of an experienced oncology RN? •LPN/LVN who has floated from the same-day surgery unit •RN from a staffing agency who is being oriented to the oncology unit •LPN/LVN with 2 years of experience on the oncology unit •RN who recently transferred to the oncology unit from the emergency department
•LPN/LVN with 2 years of experience on the oncology unit •Because many aspects of nursing care need to be modified to prevent infection when a patient has a low absolute neutrophil count, care should be provided by the staff member with the most experience with neutropenic patients. The other staff members have the education required to care for this patient but are not as clinically experienced. When LPN/LVN staff members are given acute care patient assignments, they must work under the supervision of an RN. The LPN/LVN in this case would report to the RN assigned to the patient.
A patient who has sickle cell disease is admitted with vaso-occlusive crisis and reports severe abdominal and flank pain. Which of the analgesic medications on the pain treatment protocol will be *best* for the nurse to administer initially? •Ibuprofen 800 mg PO •Morphine sulfate 4 mg IV •Hydromorphone liquid 5 mg PO •Fentanyl 25 mcg/hr transdermal patch
•Morphine sulfate 4 mg IV •Guidelines for the management of vaso-occlusive crisis suggest the rapid use of parenteral opioids for patients who have moderate to severe pain. The other medications may also be appropriate for the patient as the crisis resolves but are not the best choice for rapid treatment of severe pain.
A patient who has been receiving cyclosporine following an organ transplantation is experiencing these symptoms. Which one is of *most* concern? •Bleeding of the gums while brushing the teeth •Nontender lump in the right groin •Occasional nausea after taking the medication •Numbness and tingling of the feet
•Nontender lump in the right groin •A nontender lump in this area (or near any lymph node) may indicate that the patient has developed lymphoma, a possible adverse effect of immunosuppressive therapy. The patient should receive further evaluation immediately. The other symptoms may also indicate side effects of cyclosporine (gingival hyperplasia, nausea, paresthesia) but do not indicate the need for immediate action.
These activities are included in the care plan for a 78-year-old patient admitted to the hospital with anemia caused by possible gastrointestinal bleeding. Which activity can the nurse delegate to an experienced unlicensed assistive personnel (UAP)? •Obtaining stool specimens for fecal occult blood test (FOBT) •Having the patient sign a colonoscopy consent form •Giving the prescribed polyethylene glycol electrolyte solution •Checking for allergies to contrast dye or shellfish
•Obtaining stool specimens for fecal occult blood test (FOBT) •An experienced UAP will have been taught how to obtain a stool specimen for the fecal occult blood test because this is a common screening test for hospitalized patients. Having the patient sign an informed consent form should be done by the health care provider who will be performing the colonoscopy. Administering medications and checking for allergies are within the scope of practice of licensed nursing staff.
A patient in a long-term care facility who has anemia reports chronic fatigue and dizziness with minimal activity. Which nursing activity will the nurse delegate to the unlicensed assistive personnel (UAP)? •Evaluating the patient's response to normal activities of daily living •Obtaining the patient's blood pressure and pulse with position changes •Determining which self-care activities the patient can do independently •Assisting the patient in choosing a diet that will improve strength
•Obtaining the patient's blood pressure and pulse with position changes •UAP education covers routine nursing skills such as assessment of vital signs. Evaluation, baseline assessment of patient abilities, and nutrition planning are activities appropriate to RN practice.
The nurse is making a room assignment for a newly arrived patient whose laboratory test results indicate pancytopenia. Which patient will be the *best* roommate for the new patient? •Patient with digoxin toxicity •Patient with viral pneumonia •Patient with shingles •Patient with cellulitis
•Patient with digoxin toxicity •Patients with pancytopenia are at higher risk for infection. The patient with digoxin toxicity presents the least risk of infecting the new patient. Viral pneumonia, shingles, and cellulitis are infectious processes.
Which of these patients who have just arrived at the emergency department should the nurse assess *first*? •Patient who reports several dark, tarry stools and a history of peptic ulcer disease •Patient with hemophilia A who is experiencing thigh swelling after a fall •Patient who has pernicious anemia and reports paresthesia of the hands and feet •Patient with thalassemia major who needs a scheduled blood transfusion
•Patient with hemophilia A who is experiencing thigh swelling after a fall •Thigh swelling after an injury in a patient with hemophilia likely indicates acute bleeding, which can compromise blood flow and nerve function in the leg and should be treated immediately with the administration of factor replacement. The other patients also need assessment, treatment, or both, but the data do not indicate any immediate threat to life or function.
The nurse is providing orientation for a new RN who is preparing to administer packed red blood cells (PRBCs) to a patient who had blood loss during surgery. Which action by the new RN requires that the nurse intervene *immediately*? •Waiting 20 minutes after obtaining the PRBCs before starting the infusion •Starting an IV line for the transfusion using a 22-gauge catheter •Priming the transfusion set using 5% dextrose in lactated Ringer's solution •Telling the patient that the PRBCs may cause a serious transfusion reaction
•Priming the transfusion set using 5% dextrose in lactated Ringer's solution •Normal saline, an isotonic solution, should be used when priming the IV line to avoid causing hemolysis of red blood cells (RBCs). Ideally, blood products should be infused as soon as possible after they are obtained; however, a 20-minute delay would not be unsafe. Large-bore IV catheters are preferable for blood administration; if a smaller catheter must be used, normal saline may be used to dilute the RBCs. Although the new RN should avoid increasing patient anxiety by indicating that a serious transfusion reaction may occur, this action is not as high a concern as using an inappropriate fluid for priming the IV tubing.
A patient with acute myelogenous leukemia is receiving induction-phase chemotherapy. Which assessment finding requires the *most* rapid action? •Serum potassium level 7.8 mEq/L (7.8 mmol/L) •Urine output less than intake by 400 mL •Inflammation and redness of the oral mucosa •Ecchymoses present on the anterior trunk
•Serum potassium level 7.8 mEq/L (7.8 mmol/L) •Fatal hyperkalemia may be caused by tumor lysis syndrome, a potentially serious consequence of chemotherapy in acute leukemia. The other symptoms also indicate a need for further assessment or interventions but are not as critical as the elevated potassium level, which requires immediate treatment.
A transfusion of packed red blood cells (PRBCs) has been infusing for 5 minutes when the patient becomes flushed and tachypneic and says, "I'm having chills. Please get me a blanket." Which action should the nurse take *first*? •Obtain a warm blanket for the patient •Check the patient's oral temperature •Stop the transfusion •Administer oxygen
•Stop the transfusion •The patient's symptoms indicate that a transfusion reaction may be occurring, so the first action should be to stop the transfusion. Chills are an indication of a febrile reaction, so warming the patient may not be appropriate. Checking the patient's temperature and administering oxygen are also appropriate actions if a transfusion reaction is suspected; however, stopping the transfusion is the priority.
When administering a blood transfusion to a patient, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? •Take the patient's vital signs before the transfusion is started •Assure that the blood is infused within no more than 4 hours •Ask the patient at frequent intervals about presence of chills or dyspnea •Assist with double-checking the patient's identification and blood bag number
•Take the patient's vital signs before the transfusion is started •UAP education and role includes obtaining vital signs, which will be reported to the RN prior to the initiation of the transfusion. Monitoring for transfusion reactions, adjusting transfusion rate, and assuring that the blood type and number are correct require critical thinking and should be done by the RN.
The nurse is caring for a patient who takes warfarin daily for a diagnosis of atrial fibrillation. Which information about the patient is *most* important to report to the health care provider (HCP)? •The international normalized ratio (INR) is 5.2 •Bruising is noted at sites where blood has been drawn •The patient reports eating a green salad for lunch every day •The patient has questions about whether a different anticoagulant can be used
•The international normalized ratio (INR) is 5.2 •An INR of 2 to 3 is the goal for patients who are taking warfarin for atrial fibrillation; the INR of 5.2 will require that the medication dose be adjusted. Because bleeding times are prolonged when patients receive anticoagulants, bruising is a common adverse effect. Green leafy vegetables contain vitamin K and have an impact on the effectiveness of warfarin, but if patients eat these vegetables consistently, then warfarin dosing will also be consistent. The HCP may need to discuss use of the newer oral anticoagulants (which do not require blood testing) with the patient, but the highest concern is the very prolonged INR.
The nurse in the outpatient clinic is assessing a 22-year-old patient who needs a physical exam before starting a new job. The patient reports a history of a splenectomy several years previously after an accident but has otherwise been healthy. Which information obtained during the assessment will be of *most* immediate concern to the nurse? •The patient engages in unprotected sex •The oral temperature is 100°F (37.8°C) •The blood pressure is 148/76 mm Hg •The patient admits to daily marijuana use
•The oral temperature is 100°F (37.8°C) •Because the spleen has an important role in the phagocytosis of microorganisms, the patient is at higher risk for severe infection after a splenectomy. Antibiotic administration is usually indicated for any symptoms of infection. The other information also indicates the need for more assessment and intervention, but prevention and treatment of infection are the highest priorities for this patient.
The nurse obtains the following data about a patient admitted with multiple myeloma. Which information requires the *most* rapid action by the nurse? •The patient reports chronic bone pain •The blood uric acid level is very elevated •The 24-hour urine test shows Bence Jones proteins •The patient reports new-onset leg numbness
•The patient reports new-onset leg numbness •The leg numbness may indicate spinal cord compression, which should be evaluated and treated immediately by the health care provider to prevent further loss of function. Chronic bone pain, hyperuricemia, and the presence of Bence Jones proteins in the urine all are typical of multiple myeloma and do require assessment or treatment; however, the loss of motor or sensory function is an emergency.
A patient with iron deficiency anemia who is taking oral iron supplements is evaluated by the nurse in the outpatient clinic. Which finding by the nurse is of *most* concern? •The patient reports that stools are black •The patient complains of occasional constipation •The patient takes a multivitamin tablet every day •The patient takes an antacid with the iron to avoid nausea
•The patient takes an antacid with the iron to avoid nausea •Concurrent use of antacids with iron supplements will decrease absorption of the iron and decrease the efficacy in resolving the patient's anemia. Black stools are expected when taking oral iron. The patient's occasional constipation may indicate a need for information about prevention of constipation while taking iron. Use of a multivitamin tablet is safe when taking iron supplements (although the patient may need to avoid taking combined vitamin and mineral supplements).
The nurse is transferring a patient with newly-diagnosed chronic myeloid leukemia to a long-term care facility. Which information is *most* important to communicate to the nurse at the long-term care facility before transferring the patient? •Philadelphia chromosome is present in the patient's blood smear •Glucose level is elevated as a result of prednisone therapy •There has been a 20-lb (9.1-kg) weight loss over the last year •The patient's chemotherapy has resulted in neutropenia
•The patient's chemotherapy has resulted in neutropenia •A patient with neutropenia is at increased risk for infection, and the nurse who will be receiving the patient needs to know about the neutropenia to make decisions about the patient's room assignment and to plan care. The other information also will impact planning for patient care, but the charge nurse needs the information about neutropenia before the patient is transferred.
A patient is admitted to the intensive care unit with disseminated intravascular coagulation (DIC) associated with a gram-negative infection. Which assessment information has the *most* immediate implications for the patient's care? •There is no palpable radial or pedal pulse •The patient reports chest pain •The patient's oxygen saturation is 87% •There is mottling of the hands and feet
•The patient's oxygen saturation is 87% •Because the decrease in oxygen saturation will have the greatest immediate effect on all body systems, improvement in oxygenation should be the priority goal of care. The other data also indicate the need for rapid intervention, but improvement of oxygenation is the most urgent need.
A patient with chemotherapy-related neutropenia is receiving filgrastim injections. Which finding by the nurse is *most* important to report to the health care provider? •The patient says, "My bones are aching." •The patient's platelet count is 110,000 mm3 (110 × 109/L) •The patient's white blood cell count is 39,000 mm3 (39.0 × 109/L) •The patient reports that the medication stings when it is injected
•The patient's white blood cell count is 39,000 mm3 (39.0 × 109/L) •Leukocytosis is an adverse effect of filgrastim and indicates a need to stop the medication or decrease dosage. Bone pain is a common adverse effect as the bone marrow starts to produce more neutrophils; the patient should receive analgesics, but the medication will be continued. Stinging with injection may occur; the nurse should administer the medication more slowly. The patient's platelet count is low and should be reported, but the level of 110,000 mm3 (110 × 109/L) does not increase risk for spontaneous bleeding.
After a car accident, a patient with a medical alert bracelet indicating hemophilia A is admitted to the emergency department. Which action prescribed by the health care provider will the nurse implement *first*? •Transport to the radiology department for cervical spine radiography •Transfuse factor VII concentrate •Type and cross-match for 4 units of packed red blood cells (PRBCs) •Infuse normal saline at 250 mL/hr
•Transfuse factor VII concentrate •When a hemophiliac patient is at high risk for bleeding, the priority intervention is to maximize the availability of clotting factors. The other prescribed actions also should be implemented rapidly but do not have as high a priority as administering clotting factors.
The nurse is reviewing the complete blood count for a patient who has been admitted for knee arthroscopy. Which value is *most* important to report to the health care provider before surgery? •Hematocrit of 33% (0.33) •Hemoglobin level of 10.9 g/dL (109 g/L) •Platelet count of 426,000/mm3 (426 × 109/L) •White blood cell count of 16,000/mm3 (16 × 109/L)
•White blood cell count of 16,000/mm3 (16 × 109/L) •Centers for Disease Control and Prevention guidelines for the prevention of surgical site infections indicate that surgery should be postponed when there is evidence of a preexisting infection such as an elevation in white blood cell count. The other values are slightly abnormal but would not be likely to cause postoperative problems for knee arthroscopy.