HESI: Delegation of Nursing Management and Rationale

11. The charge nurse then recalls that they need to follow up on a few things. Which actions taken during the shift will require follow up that morning? (Select all that apply. One, some, or all options may be correct.)

-Antiseptic sink cleaning and teaching of bed pan cleaning performed by the PN. (The charge nurse delegated these activities to the PN so that they could go to the waiting area and assist with the emergency there. They need to follow up and evaluate the completion of the delegated tasks to ensure that they have been performed correctly.) -Completion of morning vital signs of all clients who were on the unit since the night shift. (The charge nurse delegated this task during shift change and should evaluate the completeness and quality of the task performance by the UAPs.)

10. The charge nurse quickly calls the intensive care unit (ICU) to ask if there is a resource nurse on the unit that is trained in accessing an internally implanted venous access device. An ICU nurse arrives with a special kit for accessing an internally implanted venous access device. The charge nurse observes this procedure. Which actions should the charge nurse expect to observe when watching the ICU nurse access the implanted catheter?

-Establishes a sterile field around the access port. (Strict sterile procedure is required when accessing a central venous access device. Establishing a sterile field around the access port would be a required step in this procedure.) -Wears a gown, mask, and sterile gloves. (Strict sterile procedure is required when accessing a central venous access device. Wearing a gown, mask, and sterile gloves would be required when performing this procedure.) -Places a mask on the client over client's nasal cannula. (Strict sterile procedure is required when accessing a central venous access device. This action would be necessary to provide a barrier to keep the client's breath from contaminating the sterile field.) -Washes hands using a surgical hand scrub procedure. (Strict sterile procedure is required when accessing a central venous access device. Washing hands using a surgical scrub technique is essential before setting up a sterile field.)

15. Which duty was breached by leaving the computer open and unattended?

A duty to use due care according to the current standard for computer usage. (The nurse breached the duty to use due care according to the current standard when the computer was left open and unattended.)

8. After the charge nurse assists the nurse and the EMS personnel with placing the agitated older client into the room nearest the nurses' station, they casually greet the unlicensed assistive personnel (UAP) on their way back to the nurses' station. Upon closer observation, the charge nurse notices that the UAP is cleaning a used bedpan in a sink where staff wash their hands between clients. The triage nurse calls about an emergency occurring in the waiting area and a practical nurse (PN) is just returning from lunch. Which action should be the charge nurse's first response?

Ask the PN to have the sink cleaned and reinforce infection control teaching with the UAP. (The first action that the charge nurse should take is to delegate the infection control problem to the PN, then they should continue to the triage desk to assist with the emergency occurring there. All clients and staff could be adversely affected if the infection control issue intervention is delayed.)

4. The charge nurse sees a staff member arriving late and walking off balance. Which action is the most important intervention for the charge nurse to take?

Ask the staff member to join them in the nurse manager's office. (The charge nurse should get the manager involved with evaluating the staff member's condition. The charge nurse should also assist the manager with documenting evidence and confronting the staff member about the problem.)

20. The experienced nurse tells the charge nurse that most staff members are not making the distinction between a client arriving to the Emergency Department with police while under arrest and having police arrive to collect a client's blood sample after being admitted to the hospital. The nurse volunteers to present an in-service for staff that will be ready by next week. The charge nurse relays this meeting outcome to the unit manager. The charge nurse makes his way through the unit and casually greets another nurse on his way to the triage desk. The nurse has collected several tubes of blood from a client. The unlicensed assistive personnel (UAP) delivers the wrong client stickers to the treatment room. While starting to place the stickers onto the blood tubes, the nurse notices the error and stops. Which action is most important for the nurse to perform?

Asking the UAP where the other labels have gone. (Knowing the location of the other labels is most important because mislabeled samples may have been sent to the lab and they need to be identified and corrected as soon as possible to avoid client treatment errors made based on the results of mislabeled blood samples.)

21. The charge nurse has been notified that labels were delivered incorrectly which resulted in several blood samples almost being delivered to the lab with the wrong labels on them. After locating the labels and correcting the error, which action is most important for the charge nurse complete before the shift ends?

Ensuring the nurse completes an error event report. (The charge nurse should ensure that the nurse has completed an error event report before the shift ends. Reporting blood sample labeling errors is important for quality improvement purposes. Administrators and staff need to record these events to improve procedures to avoid another similar error from occurring in the future.)

18. The charge nurse reports the ethical problem to his unit manager. The manager encourages them to come up with a solution to this problem for the unit. Which action from the charge nurse would most effectively address this problem?

Give a staff in-service about hospital legal policies related to collecting blood. (This is the most effective response that the charge nurse can give to address the problem. By giving an in-service to all staff members, the charge nurse contributes to his unit's professional knowledge and teaches the experienced nurse about it in a non-threatening manner.)

16. The charge nurse has secured the computer and located the nurse who left it open and unattended. When counseling the nurse about the event, the nurse states that training about this type of security has never been given. The charge nurse asks about which general policies the nurse is familiar. With which policy should every nurse be familiar, particularly when accessing protected client health records?

Healthcare Insurance Portability and Accountability Act. (Every American nurse should be familiar with this important policy that was designed to protect general healthcare information and has been around since 1996. This is a policy that specifically and directly mandates protection of individual client health records.)

19. The charge nurse decides to review the hospital policy regarding blood drawing for law enforcement with the experienced nurse who almost drew blood without a warrant. Which statement made by the nurse provides the charge nurse the most assurance that the nurse understands the policy?

I haven't been making the distinction between when police bring someone in and when they request a sample after the client has been admitted. (In this statement, the nurse verbally recognizes where the knowledge gap has probably been creating the situation. This statement demonstrates that learning has occurred.)

12. Laboratory personnel call the ED charge nurse to report a critical lab result. Alex takes the call and the laboratory reports a critical absolute neutrophil count (ANC) of 800/uL (0.80 x109/L) for the client having the internally implanted venous access device. Which action is most important for the charge nurse to take after he hangs up the telephone?

Initiate neutropenic precautions for the client (Initiating neutropenic isolation precautions are the first action the charge nurse should take because this client has insufficient available neutrophils to fight infection. The laboratory called the unit to report a critical lab result because the normal ANC range is 2,500 to 8,000/uL (2.5 to 8.0/uL).)

22. After ensuring that each blood sample that was sent to the lab with the correct label on it, the charge nurse must evaluate the unit response to the occurrence and report this to the manager. Which summary would the charge nurse conclude about this event in his report?

Near-miss error event with no adverse outcome. (This is a near-miss error event with no adverse outcome to report; the error almost occurred but was caught before the healthcare error was completed. Although no one was harmed, near-miss errors are important to record to improve patient care quality to avoid the error from occurring again and possibly when the error may not be caught in time.)

7. The experienced staff nurse stops immediately and a police officer calls a police supervisor. A judge provides a warrant and then the nurse collects the blood sample. Soon, an agitated older client with acute altered mental status arrives by ambulance. The emergency medical service (EMS) personnel have the client strapped to a gurney and are standing in the hall way waiting for instructions. The triage nurse asks the charge nurse which treatment room is available for an agitated older client with acute altered mental status. Which treatment room would be the most ideal place for this client?

Room nearest the nurses' station. (This client has a higher safety risk and needs close supervision. The room nearest the nurses' station affords the entire unit to assist the nurse managing this client's care.)

17. Later that day, the charge nurse reviews the events that have transpired over the course of the shift. They are alarmed that the experienced nurse almost collected the client's blood without establishing the proper authority to do so. The charge nurse asks the experienced nurse privately about how blood collections from legal agencies have been performed in the past. The nurse tells him, that we always give the police what they need and thatt he warrant is just a technicality. The nurse states that it has never been a problem before and you will learn that when you get some more experience. Which action is most important for a charge nurse to take after hearing this response from the nurse?

Report this event and the nurse's response to the unit manager. (The unit manager should be informed, and an intervention planned and carried out.)

5. Three police officers arrive at the Emergency Department (ED). One of the officers casually asks an experienced nurse, who the police officer knows, to collect a blood sample from a comatose client who arrived by ambulance from a major accident during the previous shift. The experienced ED staff nurse begins to gather the equipment necessary for the requested blood sample and prepares to draw the blood. Which action is most important for the charge nurse to take?

Stop the staff nurse and ask the hospital supervisor about the blood sampling policy. (The police officer has not presented any legal grounds for collecting this client's blood, which should be found in the hospital policy. Many hospital policies include requiring consent by the client, requiring a legal warrant from a judge, or establishing that the client is under arrest. The charge nurse is a new to the position and should check with their resources before allowing collection of this blood sample by an outside agency without a healthcare provider prescription.)

9. The charge nurse enters the triage area and sees several staff members trying to assist an adult female client with altered mental status who is in respiratory distress. Her husband is present and says she has a history of breast cancer and she had a chemotherapy treatment yesterday. Her vital signs are as follows: temperature 104o F (40o C) heart rate 125 beats/minute respiration rate 42 breaths/minute blood pressure 96/57 mmHg oxygen saturation 87% on room air. The healthcare provider (HCP) prescribes a nasal cannula with an oxygen flow of 2 L/min. Eventually, the HCP increases the flow rate to 4 L/min and requests that a respiratory therapist bring a prefilled bubble humidifier. The client's respiration rate changes to 25 breaths/minute with an oxygen saturation of 93%. As the staff try to gain venous access, the client's husband tells them that she has an internally implanted venous access device called a port-a-cath. The staff members continue to try to gain venous access because none of them have been trained on how to access the device. Which action is the best response from the charge nurse?

Tell staff to stop and call for hospital resource nurse assistance. (Applying the nasal cannula has improved this client's vital signs. She still needs to have venous access, but she has an internally implanted venous access port. The best response would be to ask the hospital critical care unit if they have a resource nurse with internally implanted venous access device training.)

14. The nurse caring for the client on neutropenic precautions steps away from the computer for a moment to assist another nurse with client care. The charge nurse enters the room and finds the client's teenage son looking through records in the computer. Which action does the nurse need to take first?

Turn off the computer and remove it from the room if possible. (The charge nurse should turn off the computer and remove it from the room if it is portable, such as a laptop computer or a computer on wheels.)

1. After receiving report from the night shift charge nurse, which activities should the nurse anticipate completing during the first hour? (Select all that apply. One, some, or all options may be correct.)

-Delegate tasks to unlicensed assistive personnel (UAP). (Delegating tasks to UAPs for the day is a charge nurse action that should be performed during the first hour of the shift to make good use of unit personnel resources.) -Identify tasks needed for assignment and delegation. (The charge nurse should first identify the tasks needed for assignment and delegation during the first hours of the shift.) -Assign clients to staff nurses according to acuity. (Making client assignments is a charge nurse action that must be performed before or during the first hour of the shift to make the best use of unit personnel resources.) -Inspect the code cart equipment and supplies (Inspecting the code cart is a charge nurse action that must be performed during the first hour of the shift to ensure that emergency equipment is available and functional on the unit.)

3. The charge nurse checks the code cart and equipment for safety and function. Which inspections are necessary to ensure that the defibrillator is serviceable and ready for use during an emergency? (Select all that apply. One, some, or all options may be correct.)

-Electrical cords are in good repair. (Electrical cords must be in good repair to avoid a safety hazard and for the defibrillator unit to be serviceable and ready for use during an emergency.) -Defibrillator passes a system check. (The defibrillator should pass a system check at the beginning of every shift to ensure that the defibrillator unit is serviceable and ready for use during an emergency.) -Defibrillator pads/paddles are available. (Defibrillator paddles or pads are required to deliver the electrical impulse to the client during an emergency.)

13. An older adult female client with mild chest pain arrives on a gurney by ambulance. The Emergency Department is very busy, and no one has greeted her yet. The client's husband begins to get upset. He pulls a card from his wallet and shouts at the nurse nearest him. Soon everyone in the nurses' station is staring at him. He tells them, Please! Someone needs to see about my wife right now! The charge nurse witnesses the entire event. The client's husband shows his business card, which states he is a retired police officer. He begs the charge nurse to help his wife. The nurses get angry with the man and start to audibly grumble among themselves. Which response is the best way for the charge nurse to address this situation?

-Remind the staff that this man's whole world is on that gurney. (The charge nurse can deescalate this event by openly acknowledging the man's perspective to the entire staff staring at this scene. They can also have the specially trained UAP take the paramedics, the client, and the client's husband to the assigned room, start a peripheral intravenous catheter, and draw blood specimens on this client as she waits for initial assessment by a nurse.)

2. As the charge nurse considers the unit assignments and tasks for the day, they thinks about the evidence-based guidelines for delegation. Which elements are part of the Five Rights of Delegation? (Select all that apply. One, some, or all options may be correct.)

-Right supervision. (Supervision is directing, guiding, and evaluating the task performance quality of assistive personnel.) -Right circumstances. (Circumstances are a very important element of clinical decision making. The contextual elements of circumstances include policies and procedures, area of nursing, client condition, and preferred client results.) -Right task. (The right task is one that can be safely delegated for a specific client, given that client's current condition, preferred outcomes, and availability of a competent individual to perform it.) -Right instructions. (The right directions or instructions is an important part of the five rights of delegation. The person receiving delegation needs to know specifically what the delegator expects.)

23. The charge nurse has had a very eventful day on their first day as a charge nurse. They go to the charge nurse office and prepares for the incident reports they will have to ensure are completed before the end of the shift. Which events occurring during the shift would most hospital policies require reporting?

-Unauthorized access of an unattended computer. (This event has two items to report: (1) the nurse left the computer unattended and (2) a hospital client's teenaged son accessed the computer using the nurse's credentials. Each nurse is responsible for any computer access made using the nurse's credentials. This is a common policy in most hospitals and healthcare establishments.) -Impaired nurse who arrived late this morning. (This nurse should be examined by a healthcare provider and the findings reported as an incident. The board of nursing may also need to be notified after the investigation has been completed.) -Near-miss labeling issue. (Although this action did not result in an error in the clinical setting, it could have resulted in one and it is considered a near-miss event. Administrators and staff need to record these events to improve procedures and avoid an error from occurring.)

6. The charge nurse tells the staff nurse and the police officers the conditions for blood sample collection and shows them a printed copy of the hospital policy. The staff nurse tells the charge nurse, that they do this all the time and it is no problem. The staff nurse then prepares to collect the blood sample as the police observe. Which is the best action for the charge nurse to take in this situation?

Tell the nurse that this action is unethical, that it violates hospital policy, and that this procedure should stop. (The police officer has still not presented any legal basis for obtaining this blood sample and the experienced staff nurse is about to violate this comatose client's right to refuse this blood sampling as well as violate hospital policy. With this response, the charge nurse is using the evidence-based TeamSTEPPS® approach to address unsafe or unethical actions by applying the acronym CUSS (Concerned, Uncomfortable, Safety/Ethical issue, Stop).)