EAQ Prioritization and delegation
Which client should be treated first according to the National Institutes of Health Stroke Scale (NIHSS)?
Correct 3 Client with score of 3 for facial palsy
What is the priority nursing action for a client with delirium?
Correct 3 Creating a calm and safe environment
Which activity performed by the licensed practical nurse (LPN) would be appropriate while caring for a client based on the principle of right task of delegation?
Correct 3 Performing the task based on institutional policies
Which hospital care setting is most appropriate for a case manager to perform tasks as a delegatee?
Correct 4 Rehabilitative care
A client with pulmonary edema is provided care according to the functional model of nursing. The registered nurse (RN) who is in charge of providing intravenous medication every hour went on a break. Which activity performed by the RN would be most appropriate in this situation?
Correct 4 Reporting the client's condition to a charge nurse before taking a break
A health care organization is planning to implement differentiated nursing practice. What should be prepared prior to implementing this care delivery system? Select all that apply
Salary ranges Position descriptions Expected competencies Degree of participation in decision-making
A nurse is providing immediate postoperative care to a client with a tracheostomy tube in place. The client suddenly develops noisy, increased respirations and an elevated heart rate. What action should the nurse take immediately?
Suction the tracheostomy
Which client should the nurse consider to need the highest priority care?
A client with a CURB-65 score of 5
A newly promoted registered nurse (RN) is about to start delegation for the first time in her career. Which experiences foster professional self-confidence in the early career stage for an RN? Select all that apply.
Experience in clinical delegation Application of theory to practice Development of clinical judgment Engagement with a nursing mentor
The registered nurse (RN) is caring for a client with renal calculi. Which healthcare professional is most suitable to be delegated the task of administering urinary alkalinizer by mouth to the client?
LPN
The nurse is performing resuscitation interventions for airway, breathing, and circulation as part of a primary survey in a client. Which order of actions should the nurse follow for this client?
The primary survey includes assessment of airway/cervical spine, breathing, circulation, disability, and exposure. First, the nurse should establish airway patency by positioning, suctioning, and providing oxygen as needed. Assess breath sounds and respiratory effort and provide chest decompression if needed in order to assess breathing. Maintain vascular access using a large-bore catheter and use direct pressure for any external bleeding.
The registered nurse is teaching the student nurse about care provided for clients according to the five level triage system of the Emergency Severity Index (ESI). Which statement made by the student nurse indicates effective learning? Select all that apply.
"Clients who are in the ESI-4 category present with stable vital signs." "Clients with severe respiratory distress fall within the ESI-1 category.
The nurse manager is planning to assign an unlicensed healthcare worker to care for clients. What care can be delegated on a medical-surgical unit to an unlicensed healthcare worker? Select all that apply
Correct 1 Performing a bed bath for a client on bed rest Correct 4 Assisting a client who has patient-controlled analgesia (PCA) to the bathroom
What are some challenges faced in the process of delegation? Select all that apply.
Limited resources Large geographic area Vulnerable populations receiving care
What are the priority care issues during chemotherapy? Select all that apply.
Managing the client's complications Protecting the client from side effects
A healthcare team is caring for a client who underwent kidney transplantation. Which task is most suitable to be delegated to a licensed practical nurse (LPN) to provide effective client care? Select all that apply.
Recording vital signs Placing the urinary catheter
An emergency department consists of five nurses who take care of 30 clients. Which responsibility of the registered nurse is most helpful in overcoming this overwhelming situation?
span of control
Which clients are provided with cold compresses as priority nursing interventions? Select all that apply.
A client stung by scorpion A client bitten by black widow spider A client bitten by brown recluse spider
A client is severely injured with burns and sustained major trauma from a fire incident. What is the order of assessments according to priority in this situation?
A client with trauma should be assessed for airway, breathing, circulation, disability, and exposure. A jaw-thrust maneuver helps to establish an airway and breathing, and bag-valve-mask (BVM) ventilation with 100 percent oxygen source ensures ventilatory assistance. Following respiratory assessment is the circulation assessment. The pulse of the client is palpated at the radial, femoral, and carotid areas, and the systolic blood pressure is monitored. Disability is assessed using the Glasgow Coma Scale to find out the eye opening, voice, and pain status. The clothes of the client are removed with scissors to prevent fabric melting into the skin.
What does Hersey's situational leadership model describe about ability and willingness? Select all that apply.
An individual's ability does not change from one moment to the next. An individual's willingness can fluctuate from one moment to another. Ability and willingness need to be assessed to determine the level of the follower's readiness.
The client is receiving high-flow intravenous (IV) fluid replacement therapy. Which nursing assessment findings are consistent with fluid volume overload? Select all that apply.
Bounding pulse Presence of dependent edema Neck vein distention in the upright position
What points should the nurse consider when delegating a task? Select all that apply.
Checking the skill set of the delegatee Selecting the delegatee based on his or her competence levels Being certain that the delegatee is capable of completing the task
The healthcare team is caring for four clients in an emergency department. The nurse has been delegated the task to assign tags to the clients. Which client is issued the appropriate tag?
Client with major injuries- yellow tag
A client is diagnosed with cancer and is physically weak. The delegator has delegated the healthcare team members to care for the client. Which aspects of the care are most appropriate for the registered nurse (RN)? Select all that apply.
Collecting the client's medical history Teaching the client to be hopeful about the treatment Providing emotional support to the client's family members
What should the delegator do when he or she finds that a delegatee is unable to perform the given task?
Correct #4 Make sure to educate and provide feedback to the delegate
A nurse is assigned to take care of a group of clients. Which client should the nurse see first?
Correct 1 A 2-year-old client with diarrhea
The nurse is providing care to a trauma client. Which are priority nursing actions when providing care to this client? Select all that apply
Correct 1 Starting a large-bore IV Correct 2 Immobilizing any obvious deformities Correct 5 Removing clothing to allow for an adequate examination
The nurse has already removed a snakebite victim to a safe area. What action should the nurse take as the next priority in this situation?
Correct 1 The nurse should encourage the client to rest.
The registered nurse delegates care of a client with hyperpyrexia to a licensed practical nurse. How would the registered nurse achieve workable unity for an effective outcome?
Correct 2 Assisting the staff to achieve optimal functioning
The registered nurse is assisting a client who is hospitalized with high fever. Which task delegated to the unlicensed assistive personnel (UAP) would be appropriate? Select all that apply
Correct 2 Performing all hygiene tasks Correct 4 Helping the client in changing clothes
How can the lines of communication be improved in a healthcare organization during the process of delegation?
Correct 3 By appreciating and valuing each other's cultural perspectives
The registered nurse assigns a task to a newly hired licensed practical nurse (LPN) to monitor a client's blood pressure. Which is relevant to the delegator in this situation?
Correct 3 Requires more guidance
While assigning a task, the registered nurse finds that one of the delegatees is not competent to hold the current position. Which strategy does the nurse follow for managing this issue during delegation?
Correct 4 Lowering the expectations temporarily
A client is prescribed apomorphine. Which concern would be a priority while addressing patient needs?
Correct 4 Operating heavy machinery or driving
The nurse is caring for a client with breathing difficulty and is unable to auscultate any breath sounds on one side. Which action should be implemented first by the nurse?
Correct 4 Prepare for needle thoracostomy
The nurse is providing care to a client who presents in the emergency department (ED) in cardiac arrest. Which are the priority nursing actions when providing care to this client? Select all that apply.
Determining the need for rapid defibrillation Performing adequate chest compressions
The registered nurse (RN) is communicating with a healthcare team regarding the delegation of tasks. Which factors can determine the quality of communication between the RN and healthcare team? Select all that apply.
Effectiveness Meaningfulness Understandability
The registered nurse in a hospice is working with a new assistant who has prior experience working in a physician's office. Which action made by the registered nurse will promote a healthy working environment?
Encouraging the assistant to adopt the philosophy of the organization
The registered nurse is caring for a client undergoing chemotherapy. Which statement made by the client shows a need for the registered nurse (RN) to delegate unlicensed assistive personnel (UAP) to help the client with activities of daily living (ADL)? Select all that apply.
I am unable to eat on my own i have trouble getting out of bed
What comprises the prehospital priority care delivered by a nurse for a heatstroke victim?
The nurse should not give food or liquid to the victim.
A registered nurse is caring for a client according to the total client care model of nursing. Which activity performed by the nurse manager would be appropriate in this situation? Select all that apply.
Weighing the expenses of a registered nurse (RN) vs. LPNs Deciding the type of care provided by nursing assistive personnel
The nurse is working in a care area employing the "Transforming Care at the Bedside" program. The nurse wants to use the rapid cycle change process for a unit design issue. In which order should the nurse perform the steps of this process?
When implementing the rapid cycle change process, the first step is defining the objectives and predicting how the identified change would contribute to something, or in this case, contribute to cost-effective care. In the next step, the do phase, the change occurs, or in this case the item was moved. Then the study phase occurs, which in this case involves determining if the item that was moved was successful as planned. The final phase is the act phase in which the next steps are planned, or for this situation, the steps are identified to implement the change in the remaining client rooms.
Which are the highest priorities when conducting a primary client survey during the emergency assessment? Select all that apply.
airway and cervical spine
Before assigning a task, the registered nurse makes sure that the delegation process is appropriate to the situation. To which delegation right does this situation refer?
circumstance
Which class of clients during a mass casualty situation would the nurse refer to as the "walking wounded"?
class iii
