Leadership, Delegation, & Prioritization

unconscious client

When caring for a client who has been found unconscious for an unknown length of time, the nurse must first ensure the client's airway, breathing, and circulation are stabilized. Next, the nurse determines how long the client has been unconscious, when there is family at the bedside to ask. This provides important information, because the body experiences progressive and evolving physiological reactions to this state. A review of the client's medication is performed next to assess for potential medication interactions. A complete physical assessment comes after stabilization, determination of the length of unconsciousness, and medication review. Finally, constructing the plan of care occurs last.

Prioritization of care

The nurse must be able to prioritize care for several complex clients. A client with a bumpy rash who is receiving an intravenous infusion of antibiotic is at greatest risk of anaphylaxis, a life-threatening condition. This takes priority. A client reporting pain at the infusion site or moderate post-op pain will be assessed, but these do not take priority over a life-threatening condition. Additionally, a client with chronic obstructive pulmonary disease (COPD) and a decreased SpO2 on room air does not take priority, because this may be a normal finding for the client. A nurse cares for a group of clients on a busy medical-surgical unit. Which client does the nurse identify as the priority when deciding the order of care? A client receiving an intravenous infusion of levofloxacin who reports a bumpy rash on the skin Levofloxacin is an antibiotic. The client's report of symptoms indicates a likely medication allergy. A potential or actual allergic reaction takes priority, because this can be a life-threatening situation. NOT: A client who is four hours post-operative open appendectomy reporting moderate abdominal pain Addressing the client's pain is an important nursing intervention, but this is not the nurse's priority in this scenario. A client with an SpO2 of 89% on room air and a diagnosis of chronic obstructive pulmonary disease A client with chronic obstructive pulmonary disease has chronic hypoxemia and decreased SpO2. Although an SpO2 value of 89% on room air would normally be concerning and a priority, this finding is common with this diagnosis and does not represent a critical value. This is not the nurse's priority. A client receiving an IV infusion of potassium chloride who reports a dull ache at the infusion site Intravenous potassium chloride often causes a dull ache at the infusion site. The nurse assesses the client's report of pain, but this is an expected outcome of therapy and does not take priority. Assessing the priority of care for various clients is often not an easy task for a nurse. Any situation that is potentially life-threatening or may cause permanent injury always takes priority. Compartment syndrome is a medical emergency that may present as paresthesia in the affected area. This takes priority over expected findings related to disease, illness, or therapeutic regimens. A nurse cares for a group of clients on a nursing care unit. Which client does the nurse assess first? A client with a circumferential burn to the upper arm reporting tingling in the fingers A circumferential burn increases the likelihood of a client suffering from compartment syndrome, a medical emergency of increased pressure within a compartment of the body. This increased pressure decreases blood supply and causes parathesia (tingling) in the impacted area. Additional symptoms of compartment syndrome may include pain, paralysis, and decreased or absent distal pulses. NOT: A client with hepatic encephalopathy reporting tremors in the hands Hepatitis-related encephalopathy occurs when the liver is unable to rid the blood of toxins, which can damage the brain. Tremors of the extremities are an expected finding with this condition and do not take priority when planning care. A client with rhabdomyolysis reporting muscle weakness and dark brown urine Rhabdomyolysis is a condition that occurs after the breakdown of muscle tissue and subsequent damage to the kidneys. An expected finding in rhabdomyolysis is dark brown urine, and this would not take priority when planning care. A client with acute coronary syndrome on a nitroglycerin infusion reporting a dull headache Nitroglycerin is a vasodilator and causes a dull headache. This is an expected finding with this therapy and is not the priority of care when establishing priorities. When determining the prioritization of care in the post-op client, the nurse should always prioritize based on the risk of airway, breathing, and circulation compromise. The client with extreme anemia has a severe circulation issue which will also impact the ability to carry oxygen. The other clients are then prioritized based on clinical presentation and risk of harm or deterioration. 1. A client who is post-cesarean section with a hemoglobin of 8 g/dL 2. A client who is post-open appendectomy with an oral temperature of 99.4 °F (37.4 °C) 3. A client who is post-cardiac surgery with a blood pressure 90/64 mm Hg 4. A client who is post-thoracotomy with SpO2 93% on 2L per nasal cannula This is a heavy analysis question. The toughest type that you will find on the NCLEX. HBG 8: This hemoglobin level is low and may indicate the client is bleeding. This client takes priority. A hemoglobin of 8 g/dL is roughly equivalent to a hematocrit of 24%. (Multiply the hemoglobin by 3 to create a rough hematocrit estimate.) The normal hemoglobin and hematocrit for a woman are around 12 g/dL and 36%, respectively. This client has values representing potential hemorrhage and a decreased cardiac output. At first glance, this is an issue of cardiac compromise, but it is a severe and actual (not risk for) issue. Temp 99.4: Although the client's temperature is elevated, it is not a fever. Postoperative clients often exhibit a small temperature elevation due to the need to breathe deeply and cough. A quick reminder to breathe deeply and use the IS is all this patient probably needs. The client could worsen pretty quickly if this step is not taken. However, the thing that underlies this temperature (the pathophysiology) might be not just shallow breathing, but also breathing too slowly. This client is assessed after the priority client. This is an issue of breathing and possibly of poor airway clearance. BP 90/64: Although the client is borderline hypotensive (hypotension is actually LESS THAN 90/60 mmHg), it is not uncommon for clients who are post-op from cardiac surgeries to have low blood pressure. It is common to use invasive monitoring and titrate inotropic medications. This client is assessed third. For the post-cardiac surgery client who does demonstrate significant hypotension, use the mnemonic PROVED: Pump Rhythm Obstruction Volume Endocrine Distributive 93% oxygen saturation: Although the client does not have 100% saturation of oxygen, this is a normal finding for a client who is post-op from pulmonary surgery. This client will be assessed last. Often, pain medication and ambulation correct this oxygen level. - Nurse Cat Prioritization of care should be based on the severity of illness and the risk of harm. The client with severe hyponatremia is at high risk for morbidity and mortality and is assessed first. The client with a life-threatening condition that has now stabilized is addressed second. The client with compensated respiratory acidosis is addressed next, due to the risk of ventilation problems. Finally, the hemodialysis client is assessed last, because the abnormal laboratory values are normal for that particular client population. A nurse cares for a group of clients with laboratory abnormalities. In which order does the nurse plan to deliver care? (Place each option in order, from first priority to last.) 1. A client with chronic liver disease, cirrhosis, ascites, and moderate confusion with a sodium level of 120 mEq/L 2. A client with type 2 diabetes, hyperosmolar hyperglycemic syndrome, glucose of 125 mg/dL, and potassium of 3.3 mEq/L 3. A client with chronic bronchitis on bilevel positive airway pressure with ABG results including pH 7.35 and PaCO2 55 mmHg 4. A client with chronic renal failure scheduled for hemodialysis in a few hours with a current creatinine of 10 mg/dL When determining the priority of care, the nurse should be mindful of normal compensatory responses to disease states, even though a client's vital signs may be abnormal. Priority of care should be for the client who is at greatest risk for compromise, in this case, the client with carbon monoxide exposure. Correct Order 1. A client with suspected carbon monoxide exposure and a SpO2 of 98% 2. A client with a nitroglycerin IV infusion with a blood pressure of 90/68 mm Hg 3. A client with hyperthyroidism with a heart rate of 113 beats/min. 4. A client with metabolic acidosis with a respiratory rate of 20 breaths/min. Carbon monoxide binds to the hemoglobin instead of the oxygen which causes decrease of amounts of o2 to enter the cells and increase levels of CO. So on a pulse ox monitor it will detect a normal reading 94-100% but because the body is not receiving o2 the patient can deteriorate quickly. So you have to do further investigation to determine if the patient is having respiratory failure. CO exposure can cause a false SpO2 "normal" reading. Because CO binds more easily to hemoglobin than O2 does. Your Pt will have a normal SpO2 reading but appear physically flushed, bright red, and have dyspnea. Due to the fact that the CO has displaced their O2. The client scheduled for a cardiac catheterization has immediate cardiac issues. The client has cardiac circulation impairment, or it is highly suspected, hence the scheduled procedure. This client's cardiac status will be compromised if ingesting caffeine, as this is a cardiac stimulant. It is not enough to tell the unlicensed assistive personnel (UAP) to stop, because the client may call out again, and someone else might bring that coffee. Cardiac catheterization does not need to be delayed. This is usually a procedure that requires a sense of urgency, and if the client drinks anything, the procedure may be put off hours or a whole additional day. The client with left shoulder pain and numbness is likely experiencing a neurovascular or musculoskeletal issue. The nurse does not have enough information to infer that this client is having a myocardial infarction (MI) but will assess this potential circulation issue further after ensuring the client with a definite circulatory issue is addressed. An initial assessment of this client can be done in five minutes, and the nurse can reassess within 20-30 minutes if there are no other MI symptoms at this time. The post-esophagectomy client should not have nausea and is at risk for rupture of the esophageal suture line, which would require surgery. The nurse quickly handles the catheterization and coffee situation and the potential but not probable MI situation, and then the nurse administers anti-nausea medication to the post-esophagectomy client. The client requesting pain medication is last. Though terribly uncomfortable and in need of an anti-pyretic and pain medication, this client is not in any immedate danger. After the hand-off report, in which order does a nurse provide care for a group of clients? (Place each option in order, from first priority to last.) A client scheduled for a cardiac catheterization, to whom the unlicensed assistive personnel is bringing coffee A client with arthritis reporting paresthesia and sharp pain in the left shoulder A post-esophagectomy client with a nasogastric tube and mild nausea A client with a long patch of blisters on the torso and a low-grade fever, requesting hydromorphone Understanding the priority of care when determining isolation precautions is an important concept for the nurse. A client with possible varicella (chickenpox) should be isolated in order to prevent the rapid spread of infection to others. Pertussis, C. diff, and tuberculosis are all conditions that require isolation, but the nurse must know how to assess clients with these conditions and determine whether isolation is necessary. A nurse cares for a group of clients in the emergency department. Which client is placed on transmission-based precautions first? A pediatric client with a new vesicle rash and exposure to varicella Varicella (chickenpox) may spread rapidly to other clients in the emergency department. This client should be rapidly placed on airborne precautions in an effort to protect others from infection. An active airborne infection has the potential to make many more people ill than illnesses that are not probable, are not confirmed, or require droplet or contact precautions. NOT: A client with nausea taking vancomycin for a C. difficile infection This client may be placed on contact precautions to prevent the potential spread of C. diff infection, but this should occur after the isolation of the client with potential varicella infection. A client with general malaise and a history of tuberculosis exposure This client does not necessarily have tuberculosis and needs further assessment to determine whether tranmission-based precautions are needed. A pediatric client with paroxysmal coughing and exposure to pertussis This client should be placed on droplet precautions, but only after the isolation of the client with possible varicella infection.

Evidence-based practice Model

Evidence-based practice is a strategy to improve quality by using the best available knowledge, integrated with clinical experience and the client's preferences and values to provide care. There are five steps to the evidence-based practice model: 1. Identify the clinical question or problem. 2. Acquire the evidence to answer the question or solve the problem. 3. Evaluate the evidence. 4. Apply the evidence. 5. Assess the outcome.

Maslow Hierarchy of Needs Theory

The Maslow hierarchy of needs provides direction in determining priority needs for client assessment and intervention. Physiological needs take priority and include air, water, and food. When considering physiological needs, the nurse needs to remember that airway, breathing, and circulation are top priorities. Safety needs should be addressed next and include keeping the client from danger. Psychosocial needs are lower priority needs for the client. When receiving a new admission, the nurse must first assess the client in order to determine prioritization of client needs and how to plan the day according to these needs. Food is on the first level of the Maslow hierarchy of needs, forming the base. A nurse receives a report for a shift assignment. After reviewing the assignments, which client does the nurse assess first? An unconscious client who needs a tube feeding initiated This is a physical need and is the highest priority. NOT: A client with a family member who needs emotional support This is an emotional need and is a lower priority. A client who has a family member waiting to visit This is a lower priority need than a physical need. A client who is scheduled to receive a beta-blocker medication A client receiving a medication on schedule is a safety level need and would be second priority to the client with the physical need. Maslow's hierarchy of needs is a model nurses use as a basis of care. The hierarchy from bottom to top consists of physiological needs, safety and security, love and belonging, self-esteem, and self-actualization.According to this model, certain needs must be met before others. For example, physiological needs must be met before needs of love or belonging can be addressed. The hierarchy takes into account that each person is unique, and personal experiences are considered.A client's needs may not always realistically align with the order of the hierarchy, so focus should be placed on a client's needs rather than strict adherence to the hierarchy. Emergent physiological needs always take priority over other needs. An older adult client has new onset atrial fibrillation. The nurse prioritizes which nursing diagnosis as the highest priority for the client? Risk for injury related to syncope and confusion Risk for injury related to syncope and confusion is the highest priority nursing diagnosis because physiological and safety needs outweigh the client's anxiety, according to Maslow's hierarchy of needs. NOT: Risk for activity intolerance related to decreased cardiac output Risk for activity intolerance does fall into the physiological category of Maslow's hierarchy of needs, but it is not more of a threat to the client than risk for injury. Risk for anxiety related to fear of recurrent palpitations Risk for anxiety is not the highest nursing diagnosis because physiological and safety needs rank higher according to Maslow's hierarchy of needs. Risk for urinary incontinence related to increased urine output Urinary incontinence is likely embarrassing and uncomfortable for the client, but based upon Maslow's hierarchy of needs, this does not take precedence over physiological needs such as a risk for injury. The Maslow hierarchy of needs provides direction in determining priority needs for client assessment and intervention. Physiological needs take priority and include air, water, and food. When considering physiological needs, the nurse needs to remember that airway, breathing, and circulation are top priorities. Safety needs should be addressed next and include keeping the client from danger. Psychosocial needs are lower priority needs of the client. A nurse receives a report at the beginning of a day shift. Which client does the nurse assess first? A client reporting shortness of breath and difficulty breathing Shortness of breath can be a complication related to a pulmonary embolism, myocardial infarction, anaphylaxis, or other issue. The nurse must evaluate to determine whether this is an issue related to airway, breathing, or circulation, any of which could be fatal. NOT: A client who reports difficulty sleeping through the night Though the client's difficulty sleeping needs to be addressed and interventions completed, this client is not a priority. A client whose previous assessment included audible wheezing The nurse does want to ensure the client's wheezing is not progressive in nature and that the client continues to compensate effectively, but a sudden change in status in another client takes priority. A client with a report of surgical incision pain of 4/10 A client with pain needs to have interventions performed. However, even if the client had a higher pain rating, the nurse cannot make this client a priority. Following the Maslow hierarchy of needs, physiological needs take priority and include air, water, and food. When considering physiological needs, the nurse needs to remember that airway, breathing, and circulation are top priorities, in that order. (During cardiopulmonary resuscitation, the order is chest compressions, airway, breathing.) Safety needs should be addressed next and include keeping the client from danger. Psychosocial needs are lower priority needs for the client. When receiving a new admission, the nurse must first assess the client in order to determine prioritization of client needs and how to plan the day according to these needs. Food is on the first level of the Maslow hierarchy of needs, forming the base. A unit secretary calls a nurse regarding four clients who have called for assistance. Which client does the nurse assess first? A client with a pneumothorax reporting shortness of breath The client with shortness of breath needs immediate assessment to determine oxygen needs to prevent a negative outcome. NOT: A client who has an order for discharge and is ready to go home This client is stable and is a low priority. A client who is post-appendectomy reporting continuous, achy pain The client's pain needs to be addressed, but this is not an emergency, and this client can be seen after the client with shortness of breath. A client with asthma who would like to ambulate in the hallway Ambulation should be encouraged but is not an urgent need. The Maslow hierarchy of needs provides direction in determining priority needs for client assessment and intervention. Physiological needs take priority and include air, water, and food. When considering physiological needs, the nurse needs to remember that airway, breathing, and circulation are top priorities. Safety needs should be addressed next and include keeping the client from danger. Psychosocial needs are lower-priority needs for the client. When receiving a new admission, the nurse must first assess the client in order to determine prioritization of client needs and how to plan the day according to these needs. A new nurse reviews client assignments for the day, including a new admission arriving to the unit now. Which client does the nurse assess first? A newly admitted client with acute flank pain and hematuria The new admission is a priority, because assessment is required prior to determining client needs. NOT: A client who underwent a renal biopsy two days ago This client is low risk, and the nurse has no indication of immediate need. A client scheduled for hemodialysis within the next two hours This client needs to be assessed prior to leaving the unit for treatment and is not a current priority. A client with urinary retention and benign prostatic hypertrophy This client does not require immediate intervention. Retention is a normal effect of benign prostatic hypertrophy, as the prostate prevents or reduces urine flow through the urethra.

arterial insufficiency

Arterial insufficiency is any condition that slows or stops the flow of blood through the arteries. Atherosclerosis is one of the most common causes, as plaque buildup on the wall of the artery results in narrowing or occlusion. Arterial insufficiency can be distinguished from venous insufficiency by examining the color, temperature, pulse, presence of edema, and skin changes of the affected area. The nurse performs a physical assessment on a client admitted with arterial insufficiency of the right lower extremity. Which assessment findings does the nurse expect? The area is pale and cool to the touch, and the pulse is weak. Characteristics of arterial insufficiency include pale and cool skin, weak or absent pulse, absent or mild edema, and thin, shiny skin. Hair growth is often decreased in the area, and nails are thickened. NOT: The area has dilated superficial veins when in a dependent position. An area of dilated superficial veins when in a dependent position is characteristic of varicosities. The area has localized redness, tenderness, and swelling over a vessel. An area of localized redness, tenderness, and swelling over a vessel is characteristic of phlebitis, or inflammation of a vein. The area has pitting edema and brown pigmentation. Normal skin temperature, marked edema, and brown pigmented areas are indications of venous insufficiency.

Wound evisceration

Wound evisceration occurs when the wound edges separate to the extent that the intestines protrude through the wound. The nurse takes these actions in the following order: 1. The nurse positions the client in the supine position in order to decrease pressure on the wound. 2. Next, the nurse covers the protruding intestinal loops with moist saline gauze. 3. Next, the nurse asks another nurse to notify the healthcare provider regarding the client's condition. 4. Finally, the nurse observes the client for signs and symptoms of shock.

Refusal of assignment

The nurse's duty to the client begins once an assignment is accepted on the first shift worked. The nurse's right to refuse mandatory overtime varies, based on state law and facility policy. If a nurse is asked to continue working into a second consecutive shift, the nurse must use critical judgment to decide if competent care can be provided. If not, the nurse communicates in writing if unwilling or unable to work. Depending on the state, nurses who refuse to accept a work assignment after that shift's report may be charged with abandonment if qualified staff are not available to care for the clients who were assigned to that nurse. The nurse is asked to work a double shift on an understaffed unit. What is the best way for the nurse to decline an assignment? Inform the supervisor in writing. The nurse informs the immediate supervisor in writing of a refusal to accept an assignment, states alternative options to provide care for the clients, and keeps a copy of the documented refusal. Solid grounds for refusal of an assignment include religious protection, a conscience clause, or objections that uphold the public good. Additionally, nurses should always refuse assignments outside their legal scope of practice as defined by their state's Nurse Practice Act. NOT: Verbally refuse the assignment. Verbally refusing the assignment does not provide evidence of the refusal. The best way to refuse an assignment is on paper. Call the supervisor in charge. Calling the supervisor in charge to refuse the assignment is appropriate after writing a refusal of the assignment. Tell the unit charge nurse. The unit charge nurse works with the staffing provided. He or she cannot make a firm decision and has little autonomy in some institutions to bring in additional staff or allow staff to leave.

ventricular fibrillation

Ventricular fibrillation, or "V fib," occurs when impulses in the ventricles fire in a completely disorganized manner and is a medical emergency. In the rare event that this client appears stable initially, the body cannot maintain perfusion with this rhythm, requiring immediate defibrillation. If this arrhythmia continues, it will likely degenerate into asystole after a few moments. Without effective blood circulation, cardiogenic shock results, and the client will die. A nurse cares for several clients who are being monitored by telemetry. Which client does the nurse assess first? A client with a rhythm change from normal sinus rhythm to ventricular fibrillation Ventricular fibrillation is a medical emergency. The client requires immediate resuscitation. NOT: A client with an echocardiogram report that notes severe aortic stenosis Aortic stenosis is not an emergent condition, and immediate action is not required. A client who has a normal sinus rhythm admitted for intermittent tachycardia This client is the lowest risk and, while in normal sinus rhythm, does not need immediate attention. A client with a diagnosis of stable angina who calls with a report of chest pain 4/10 Chest pain in a client with stable angina is not an emergency. The nurse should provide interventions as prescribed and monitor for changes.

Evidence-based practice

Evidence-based practice is a problem-solving approach that uses current research to determine the best methods for providing client care. Evidence-based interventions are performed in a way that has been shown to result in positive and measurable outcomes, such as reducing infection, cost, or length of stay. A nurse provides care for a group of clients. Which interventions are considered evidence-based? Select All That Apply Ensure urinary catheter drainage system tubing is without kinks. Dependent loops in Foley drainage (indwelling urinary catheter) systems can lead to catheter-associated urinary tract infections. Perform a bedside report at every change of caregiver. Bedside reports are a safer, mandated method of handoff involving the client and the client's support person. Allow time for two-way communication with the client. Narrative medicine allows time for focused conversations with clients to build trust and open the lines of communication. This format of storytelling helps decrease stress and improve outcomes, and it can result in higher client satisfaction. NOT: Wash hands for at least 60 seconds with soap and water. The recommended minimum handwashing time is at least 20 seconds. Estimate urine output by visualizing the drainage bag. Urine output is measured after transferring into a graduated cylinder. Estimating will not provide accurate or useful information.

New Hire

A nurse chosen to precept a new hire is generally chosen due to experience and competence in the clinical setting. This nurse is tasked with providing guidance to the new hire by demonstrating competence and assisting this new hire to learn professional behaviors and expected competencies on the unit for which they are hired. The preceptor models professional behavior, provides constructive feedback regarding skills and behavior, and helps to promote critical thinking in the new hire. In most settings, orientation periods have a general timeline, but some new hires require additional time to acclimate to the new position. The experience should be tailored to the needs of the new hire while also taking into consideration the expectations of outcomes and the determined timeline. Periodic evaluation should be scheduled to determine whether outcomes are being met during allotted time and adjustments made as needed. Just prior to completion of a new nurse's planned orientation, an experienced nurse informs the nurse manager that additional time on orientation is needed for the new nurse. Which actions does the nurse manager take? Meet with the new nurse and the preceptor to discuss the areas of concern and determine additional time needed. Meeting with the new hire and the precepting nurse allows input from both for the determination of needs and allows the opportunity to develop a plan for completion of orientation needs. NOT: Complete orientation training as scheduled, but instruct other staff nurses to closely monitor the new hire's work. This does not address the concerns of the precepting nurse regarding the new hire's inability to perform duties independently. Terminate the new nurse due to the inability to complete training for necessary duties during the training time allotted. It is not necessary for the new hire to be terminated. There simply needs to be an evaluation of needs to help the new hire reach independence. Hold a staff meeting and discuss areas for improvement to fill in the gaps from the scheduled training time. This does not address the individual needs of the new hire or provide the opportunity to practice under supervision.

Bed rest

Bed rest is an intervention that restricts clients to bed for therapeutic reasons. The length of bed rest is determined by the client's illness or injury and their previous state of health. Bed rest has a significant impact on multiple body systems. Muscular deconditioning is apparent in a matter of days, with a loss of muscle strength at approximately 3% per day. The impact of bed rest is seen on physical systems such as metabolic, cardiac, respiratory, and gastrointestinal, but it also has psychological and social effects. When possible, the nurse should assist the client with mobility for improved health, decreased hospital stay, and increased independence. The nurse and a student nurse care for a client on bed rest. When discussing the client's care, which statement by the student nurse indicates further education is needed? "The client is at risk for orthostatic hypertension." Bed rest causes cardiac changes. Orthostatic hypotension is likely due to decreased circulating fluid volume, pooling of blood in the lower extremities, and decreased autonomic responses. Orthostatic hypotension is a drop of 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure when a client changes positions. Symptoms such as lightheadedness, dizziness, nausea, tachycardia, and fainting are possible. Orthostatic hypertension is an increase in blood pressure with movement and is not associated with bed rest. NOT: "The client on bed rest is at risk for hypostatic pneumonia." Bed rest impairs respiratory functioning by decreasing both oxygenation and productive coughing. Hypostatic pneumonia is a result of the pooled secretions, which invite bacteria and cause inflammation of the lung. "The client on bed rest is at risk for pseudodiarrhea." Bed rest impairs gastrointestinal functioning due to decreased motility and constipation. Pseudodiarrhea may result from severe constipation that becomes a fecal impaction and is the liquid stool that passes around the impaction. "The client on bed rest is at risk for a negative nitrogen balance." Bed rest decreases appetite and may result in insufficient protein intake. Despite decreased intake, the body continues to synthesize proteins and break them down into amino acids. The imbalance creates a negative nitrogen balance and can result in weight loss, decreased muscle mass, and weakness.

Heart failure

Clients with heart failure should be taught to focus on reducing modifiable risk factors such as diet. Nutrition therapy is aimed at reducing fluid retention in order to reduce the workload of the heart. Sodium causes fluid retention and should be limited or completely restricted based upon the severity of heart failure. The nurse cares for a client with heart failure. The nurse knows diet education is understood when the client selects which meal option? Baked chicken with carrots and potatoes Baked chicken with carrots and potatoes would be a good selection for a client with heart failure because it represents a low-sodium diet. NOT: Salt and peppered turkey with broccoli Clients with heart failure may be placed on a no added-salt diet. Therefore, foods seasoned with added salt would not be an appropriate food option. Salmon with asparagus and canned beans Canned foods are often high in sodium and are not a good choice for clients needing to reduce salt intake. Ham sandwich with a salad and fruit The client should reduce sodium in the diet to avoid worsening heart failure. Ham has high sodium content and would not be a good food choice.

Nurse to client ratio

Considering safety first, the charge nurse recognizes that the care of this many sick clients is beyond the scope of 1 RN and 3 UAPs. Healthcare laws address safe nurse-to-client ratios, and each state has expectations to be followed by institutions in order to ensure quality client care. The day shift charge nurse makes assignments for the oncoming shift. Two of the scheduled registered nurses (RNs) report sick for the shift. This leaves 1 RN and 3 unlicensed assistive personnel (UAP) to care for 10 clients on the pediatric cancer unit. Which action does the charge nurse take? Contact the nursing supervisor and request another RN Another RN is needed to carry the responsibility of assessing and managing the care of 10 clients. NOT: Ask another nurse to administer some of the next scheduled medications before leaving. Asking another nurse to administer medications prior to leaving would not address the need for management of care required for 10 clients throughout the shift. Medications administered too early may also have adverse consequences. Delegate as much of the client care as possible to the UAP Delegating care to the UAP does not account for the need of an additional nurse to plan and delegate care for 10 clients. Contact the nurse manager and request additional UAPs Additional UAPs do not relieve the large responsibility of 10 clients for one RN to care for.

Continuity of care

Continuity of care is concerned with quality of care over time. It is the process by which the patient and his/her physician-led care team are cooperatively involved in ongoing health care management toward the shared goal of high quality, cost-effective medical care. A client who has a new ostomy requires extensive teaching in order to make sure the client can provide care of the ostomy at home. A referral to home health services for ostomy care provides the client with the continuity of care the client requires. Referrals for assessment of self-image, equipment needed for the ostomy, and local support groups for clients with ostomies do not promote the continuity of care in the client with a new ostomy. A nurse cares for a client with a new ostomy. Which nurse-initiated referral best supports the client's continuity of care? Home health care nursing services A client with a new ostomy requires extensive teaching about the care of the ostomy. A referral to home health services for this need supports the continuity of care for this client. NOT: Therapist for assessment of self-image A client with a new ostomy is at risk for self-image problems, but this does not support the continuity of care the client needs at this time. Durable medical equipment company The client first requires extensive teaching on the new ostomy prior to ordering new supplies. This referral does not best support the client's continuity of care. Local ostomy support group A referral to the local ostomy support group may be beneficial to the client, but this does not support continuity of care for the client. Rather, this supports the client's psychosocial and emotional needs.

Critical Pathways of Care (CPCs)

Critical pathways are used to guide client care and refer to the expected outcomes and care strategies developed collaboratively by the care team. Due to improved communication among clinicians, clinical pathways have been shown to reduce costs of care and reduce lengths of stay, improving client outcomes. Critical pathways do not impact nurse staffing or nurse turnover rates. A nurse manager works to implement the use of critical pathways on the unit. What outcome is expected with this implementation? Select All That Apply Reduction of length of stay Critical pathways lead to a reduction in the length of stay, because these improve efficiency in care provided to the client. Critical pathways also promote collaboration among healthcare providers and nurses, which leads to reduction in the length of stay for the client. Reduction of costs Critical pathways lead to decreased cost of care, because critical pathways improve efficiency and decrease duplication or unnecessary care. Improved communication Critical pathways improve interdisciplinary communication because of the collaborative nature of critical pathways. This leads to improved client outcomes. NOT: Improved staffing ratios Critical pathways do not improve staffing ratios for client care. Reduction of nurse turnover Critical pathways do not reduce nurse turnover.

Digoxin

Digoxin is used to treat heart failure and atrial fibrillation. It has a low therapeutic index and requires regular blood level monitoring to ensure levels are appropriate. Because this client has renal failure, the risk for toxicity is higher.Toxicity can occur with drug noncompliance and in clients with renal dysfunction because the primary route of excretion is through the kidneys.Signs of digoxin toxicity include bradycardia, headache, nausea, dizziness, confusion, and visual disturbances. The medication dose should be changed by the healthcare provider, or a new prescription should be given. An older adult client with renal failure comes to the emergency department with a report of nausea and vomiting. The client's heart rate is 45 beats/min. The nurse is most concerned about which medication that the client takes? Digoxin A heart rate of 45 beats/min. is a potentially serious effect that can be caused by the inotropic medication digoxin as levels build up. This is especially significant in older adults whose kidneys may not be functioning normally and may not properly excrete the drug. NOT: Nitroglycerin Nitroglycerin, an antianginal, does not cause bradycardia, but it can result in hypotension. Doxorubicin Bradycardia is not a side effect of the antineoplastic doxorubicin. Furosemide Furosemide, a diuretic, does not cause bradycardia, but it can result in hypotension.

Documentation

Documentation is very important. It provides a legal record of the interventions performed by the nurse. If it was not charted, then legally, it was not done. A new nurse has difficulty with time management on the first scheduled shift. There are still multiple tasks to be completed at the end of the shift. Which priority task does the nurse do first? Document assessments and care provided during the shift Documentation of assessments and care completed is important for the oncoming shift to be able to provide continuity of care. NOT: Stock each assigned room with needed supplies for the next shift Access to needed supplies for clients is important but is not a priority and can be done by the oncoming shift, if necessary. Empty the trash and pick up dirty linen from each room This is part of maintaining a clean environment for the client but is not a priority. Report briefly on each client to the charge nurse. The charge nurse does need an update on each client. Though this is quickly done, the actual priority for the nurse is to ensure care is documented.

Active Health Promotion

Health promotion activities can be passive or active. A passive health promotion activity is one in which the individual gains from the activity of others without acting themselves. An active health promotion activity is one in which the individual gains by being actively involved in measures to improve their present and future level of wellness while decreasing the risk of disease. The nurse discusses health promotion with a client. The client demonstrates an active health promotion strategy by which action? The client applies sunscreen daily. Applying sunscreen helps protect skin from damaging ultraviolet rays. This is an example of active health promotion, as the client has to make an effort to perform the action daily to gain the benefits of sun protection. NOT: The client drinks vitamin D fortified milk. Vitamin D helps with the absorption of calcium and phosphorus in the small intestine. Vitamin D deficiency can lead to abnormalities in bone metabolism such as rickets or osteomalacia. Fortified food and drink provide most of the vitamin D in the American diet. Drinking fortified milk is an example of passive health promotion because the client is benefiting from a program directed to all drinkers of fortified milk. The client eats hamburger sold in the United States. Meat sold in the United States undergoes mandatory federal inspection to ensure the products are safe, wholesome, and correctly labeled and packaged. This is an example of passive health promotion because the client benefits from a program directed to all meat consumers. The client drinks fluoridated tap water. Municipal drinking water is fluoridated in the United States to help reduce the incidence of tooth decay. This is an example of passive health promotion because the client benefits from a program directed to all municipal water drinkers.

Forgetting to chart

If a nurse forgets to chart information and is no longer on the unit, the nurse taking over may chart omitted entries for that nurse. Note that the nurse entering the omitted charting must document the name of the nurse providing the information and that the information was obtained over the phone. After leaving the hospital for the weekend, the night shift nurse remembers forgetting to chart a urine output in the electronic medical record (EMR) for a client. What is the best way to document the information in the client's health record? The night shift nurse calls and asks the day shift nurse to document output information. Medical personnel should never chart the actions of others as though they performed them, but if a nurse has left for the day and calls back with information that needs to be documented in a timely manner (such as output), the currently assigned nurse documents this information, the source, and how the information was communicated. NOT: Instruct the night shift nurse that they need to return to chart the omitted information. The nurse may call the hospital to ask a nurse to chart something like an output, but if the nurse forgot to chart a large amount of information, the nurse may need to return to the hospital to correct the chart. The day shift nurse documents information from the client regarding output. The day shift nurse should not rely on the client to recall output information related to output that was gathered by a previous nurse without confirming the total volumes with the previous nurse. The night shift nurse charts a late entry related to output on Monday evening in the EMR. A late entry or addendum is appropriate if the healthcare personnel does not remember the charting omission until the next day, or if the charting omission does not affect care for the client. Urine output may alter the therapies the client receives, so it must be charted immediately.

Nursing responsibility during delegation

Many hospital units have UAPs obtain and record client vital signs. This does not diminish or eliminate the nurse's responsibility for client care regarding vital signs assessment. The UAP has the responsibility to report any abnormal vital signs to the nurse. The nurse then has the responsibility to verify the results.In clients with atrial fibrillation, heart rates taken with a machine are often inaccurate due to the client's irregular heart rhythm. In this situation, the nurse should reassess the heart rate manually to verify the accuracy of the result, and then notify the healthcare provider if the heart rate is still out of the expected range. The nurse delegates obtaining a client's vital signs to the unlicensed assistive personnel (UAP). The UAP reports to the nurse a heart rate of 30 beats/min. on a client with atrial fibrillation. Which action does the nurse take? Assess the client and recheck the heart rate apically for one minute. Readings taken with an automatic vital signs machine may not be accurate on clients with atrial fibrillation. The nurse should first reassess the heart rate apically to verify accuracy of the result before taking any other action. NOT: Call the healthcare provider to report the heart rate and await a new prescription. The nurse should verify that the heart rate is accurate before calling the healthcare provider. Carrying out a prescription based on inaccurate vital signs may cause an adverse event. Hold the client's dose of metoprolol. Without knowing if the heart rate is accurate, metoprolol, a beta blocker, should not be held. Furthermore, medication should not be held without a prescription from the healthcare provider. Wait until the next set of vital signs to reassess. In clients with atrial fibrillation, a heart rate that is taken with a machine can be inaccurate due to the irregular heart rhythm. A heart rate this low is not normal for atrial fibrillation. Delegation involves the registered nurse (RN) passing the responsibility for completion of a task to another individual whose scope of practice includes the task. The nurse who delegated the task still remains accountable. The nurse first assesses and determines priority needs and eligible staff for completion of the task. In order to delegate, nurses need to be aware of Nurse Practice Acts in the location of practice and scope of practice of individuals to whom they are delegating. The nursing process cannot be delegated. Even though tasks may be delegated to other nursing personnel, the RN is still legally accountable for all nursing care tasks. A nurse educates a nurse graduate about the responsibility for delegated tasks. Which statement by the graduate nurse requires additional teaching? "If the client falls when the unlicensed assistive personnel assists the client to the bathroom, the unlicensed assistive personnel should contact the provider." It is the duty of the registered nurse to perform an assessment of the client who has fallen and to contact the health careprovider with data. NOT: "After the unlicensed assistive personnel obtains vital signs, I need to review the documentation and determine whether they are within normal limits." It is the duty of the registered nurse to review data collected by the unlicensed assistive personnel and determine whether there is a need to contact the healthcare provider based on the findings. "If the client has a reaction to a medication administered by the practical nurse, I need to assess the client." The nurse is responsible for the outcome of the administration of medications by the licensed professional nurse and should assess clients to determine response. "I need to review the assessment documented by the practical nurse after performing my own assessment on each client." The registered nurse is responsible for co-signing the assessment of the practical nurse but must complete an assessment to validate findings.

Mass-casualty triage

Mass-casualty triage is a key process in any multicasualty response. The process rapidly sorts ill or injured clients into categories based on their acuity and survival potential. Most mass-casualty response teams in the field and in the hospital setting use the disaster triage tag system to categorize triage priority by color.Green-tagged clients can overwhelm a disaster situation because they come to the hospital by private vehicle and make it difficult to estimate the number of casualties that will arrive. The nurse triages clients following a multicasualty incident using the disaster triage tag system. An awake, alert, and oriented client with shallow lacerations of the extremities is examined. Which color tag is assigned to this client? The client is assigned a green tag. Green tags are assigned to clients who are non urgent or "walking wounded" (class III). They have minor injuries, and treatment can be delayed for more than 2 hours without concern. Examples include closed fractures, sprains, abrasions, and contusions. This is the appropriate tag for this client. NOT: The client is assigned a yellow tag. Yellow tags are assigned to clients who can wait a short time for care (class II). They have minor injuries such as open fractures with a distal pulse or large wounds that need attention within 30 minutes to 2 hours. A yellow tag is not appropriate for this client. The client is assigned a red tag. Red tags are assigned to clients considered emergent (class I). They have immediate threats to life such as airway obstruction or shock. A red tag is not appropriate for this client. The client is assigned a black tag. Black tags are assigned to clients who are expected to die or have already died (class IV). A black tag is not appropriate for this client.

Creating Policies

Nurses are capable of creating policies and procedures with input from management and other necessary departments. All staff will refer to many policies to provide safe and effective client care. Furthermore, when being surveyed by The Joint Commission, staff may be asked to refer to such policies. Therefore, it is prudent to apply evidence-based research during development. When creating policies and procedures it is also important to go through the appropriate channels and to be compliant with process development in the organization. 1. The first step should be to identify the information that needs to be addressed so that the goals of the policy are effectively met. 2. Evidence-based research should be gathered to ensure information reflects best practice and to ensure those following the policy provide safe care. 3. Once research is collected, feedback should be obtained from unit-based healthcare professionals. Collecting feedback from those who will be implementing the policy is important to ensuring compliance. 4. A draft of the policy with supporting evidence should be already prepared before presenting it to the direct manager. Input should be gathered and implemented into the policy as appropriate. 5. Present the proposed policy to a direct manager and obtain input. 6. Once the policy has gone through the appropriate authoritative channels and has been approved, it should be distributed to all affected staff via written and verbal communication.

Nurse evaluations

Nurses are evaluated based on standards of their professional role related to the quality of care, evaluation of practice, completion of established continuing education requirements, with consideration of teamwork, collaboration, utilization of resources, and leadership skills. Nurses should have the opportunity to provide information about their own strengths and weaknesses and to establish goals for improvement. There should be input from staff in direct supervisory roles for the nurse. A nurse receives an annual evaluation from the nurse manager on the assigned unit. Which are included in the performance evaluation of a registered nurse? Select All That Apply Nurse manager-identified goals and expectations for the upcoming year The nurse manager and the employee should identify goals and expectations for the upcoming year. Nurse manager- and employee-identified areas of strength Both the nurse manager and the employee should have the opportunity to identify strengths. Nurse manager- and employee-identified areas for improvement Both the nurse manager and the employee should have the opportunity to identify areas where improvement is required. NOT: Comparison of strengths and weaknesses with other staff on the unit The manager should not compare the performance of one staff member with that of another. Reports from colleague nurses regarding strengths and weaknesses Fellow nursing colleagues, unless in a supervisory position, do not always participate in performance evaluations of fellow employees.

Alarms

Nurses often hear numerous alarms sounding at the same time. The experienced nurse must understand what these various alarms are in order to determine which alarm should be prioritized for troubleshooting first. A low-pressure alarm on a mechanical ventilator presents a life-threatening situation, because it may indicate a client disconnect from the ventilator. Additional alarms on infusion pumps, enteral feeding pumps, and pulse oximeters need to be addressed according to the client situation. A nurse hears various alarms sounding from different client rooms. Which alarm does the nurse address first? Low-pressure alarm on the mechanical ventilator A low-pressure alarm on the mechanical ventilator may indicate a disconnect in the circuit. This may mean the client is disconnected from the ventilator and not getting artificial respirations. This is the priority alarm the nurse addresses first. NOT: Occlusion alarm on the pump infusing parenteral nutrition An occlusion alarm on the infusion pump needs to be addressed by the nurse, but this does not take priority. Increased heart rate alarm on a continuous pulse oximeter An alarm from the continuous pulse oximeter needs to be addressed by the nurse. The pulse oximeter is often not the most reliable method to obtain a heart rate, and the alarm does not take priority. Occlusion alarm on the enteral pump infusing a nutritional formula An occlusion alarm on the enteral feeding pump often can be resolved with simple troubleshooting. An occlusion does not present an immediate life-threatening situation to the client and is not the priority alarm to assess.

Nursing and Collaborative Management

Nurses work to collaborate on the care of clients in order to meet established goals and to prioritize care based on needs determined from assessment and diagnosis. Nurses work in collaboration with clients and their families, a variety of healthcare providers, pharmacists, social workers, physical therapists, medical assistants, and others to pool knowledge, reasoning, and critical thinking skills that promote or restore health. A nurse receives a school-age client who sustained a broken arm in a snowmobile accident. Collaboration with which team members is essential for this client? Select All That Apply Case manager A case manager or social worker is consulted after a traumatic event with a child to evaluate for signs of neglect or abuse. Physical therapist The physical therapist can help with improving the range of motion and muscle strength lost as a result of injury. NOT Dietitian There is no indication for dietary needs assessment with a broken arm. Respiratory therapist There is no respiratory therapy indication for this client. Home health nurse There is no need for a home health nurse for a broken arm. Effective professional collaboration leads to improved overall client outcomes. Measured improved outcomes include improved pain control, decreased length of stay, decreased mortality, and a decreased nurse turnover rate. An improved nurse-client ratio does improve client outcomes, but this is not a result of improved collaboration. A nurse manager gathers data for a staff in-service regarding the importance of collaboration and its impact on client outcomes. Which collaboration and client outcomes does the nurse include in the teaching? Select All That Apply Decreased mortality Effective professional collaboration has been shown to decrease the mortality of clients, because collaboration leads to fewer medication errors and improved client outcomes. Decreased nurse turnover rate An effective collaborative work environment improves the nurse's perception of client care and is associated with decreased nurse turnover. Improved pain control Collaboration has been shown to improve client pain control. This is most likely due to improved communication among clinicians and a quicker response to the client's needs. Decreased length of stay Effective professional collaboration leads to decreased length of stay because of increased efficacy of care. The shorter a client stays in the hospital, the better the outcome for the client. NOT: Improved nurse-client ratios Collaboration does not directly impact nurse-client ratios; these are typically mandated by individual state laws. A collaborative work environment requires the nurse to use excellent communication skills. A lack of motivation, skill, or time may contribute to decreased collaboration, but these are not the primary barriers to collaborative efforts. Communication Frequent, skilled communication is necessary for a collaborative work environment. Without communication, collaboration is not possible.

Nursing diagnosis

Nursing diagnoses are based on findings that are subjective (client's report) and objective (symptoms observed by the nurse). Nursing diagnoses include components that can be measured and observed, along with the client's stated symptoms. The nurse on a cardiac floor prepares a nursing care plan for a client with heart failure and excess fluid volume. Which nursing diagnosis is appropriate for this client? Excess fluid volume related to decreased cardiac output as evidenced by weight gain and shortness of breath The nurse knows that congestive heart failure results in decreased cardiac output, which causes an increase of fluid retained in the body. This excess fluid backs up into the lungs causing shortness of breath. It can also cause fluid to remain in the body and extremities causing edema. The overall excess fluid volume in the body also causes weight gain. NOT: Heart failure related to decreased cardiac output as evidenced by venous stasis ulcers Nursing diagnoses should not include medical diagnoses like "congestive heart failure." The nursing diagnosis is based on the medical diagnosis but is related to symptoms and conditions. Heart failure related to excess fluid volume as evidenced by shortness of breath at rest Nursing diagnoses should not include medical diagnoses like "congestive heart failure." The nursing diagnosis is based on the medical diagnosis but is symptoms- and condition-related. Fluid volume excess related to decreased cardiac output as evidenced by a cough A cough is not sufficient evidence of deceased cardiac output and could be a characteristic of a different abnormal process without additional factors present.

Kyphosis (hunchback)

Postural abnormalities can be congenital or acquired. They impact the efficiency of the musculoskeletal system, body alignment, balance, mobility, and appearance. Identifying postural abnormalities during assessment helps the nurse to plan care including lifting, transfer, positioning, and range of motion. The nurse performs a musculoskeletal assessment on a client with kyphosis. Which physical characteristics does the client display? The client's posterior curvature of the thoracic spine is exaggerated. An exaggeration of the posterior curvature of the thoracic spine is a postural abnormality called kyphosis, or hunchback. It is commonly seen in older adults. NOT: The client is rigid with an arched back and head thrown backward. A rigid position with an arched back and the head thrown backward is a postural abnormality called opisthotonos. This posture indicates reduced brain functioning or injury to the nervous system. The client displays a lateral spinal curvature that appears S-shaped. A lateral spinal curvature that appears S- or C-shaped is a postural abnormality called scoliosis. The client has an exaggeration of the curvature of the lumbar spine. An exaggeration of the curvature of the lumbar spine is a postural abnormality called lordosis, or swayback.

Nursing Process

The evaluation phase of the nursing process involves measuring the effectiveness of the interventions implemented in the plan of care, which includes reassessing pain after administering pain medication. The proper sequence of events in the nursing process is performing an assessment, assigning a nursing diagnosis, planning, implementing, and evaluating. The nurse's assessment provides the information needed to identify problems affecting the client or problems the client is at risk for developing. The nurse can then develop a nursing diagnosis, plan appropriate interventions to prevent or resolve the problem, and then evaluate. The nurse should involve other members of the interdisciplinary team as necessary to implement the plan of care. The nursing process is a system with a goal of delivering organized client-centered care. The core of the nursing process consists of performing an assessment, creating a nursing diagnosis, making a plan, implementing the plan, and evaluating it. The system of the nursing process also includes input, output, feedback, and content. Input is the data that is collected from a client assessment. Output is the result of the system and is whether the client's condition stays the same, improves, or declines. The purpose of feedback is to show how the system is functioning. Outcomes are a form of feedback because they reflect the response to nursing interventions. Feedback also includes information from family and other healthcare professionals. The product and information attained from the system is the content portion of the system. An example of this would be a client with impaired mobility having skin care needs and interventions for them. The nurse cares for an immobile client. The nurse teaches a new nurse graduate about the nursing process. Which action accurately depicts the nursing process? Documenting improvement of the client's status as a result of the nurse's care. The nursing process also includes input, output, feedback, and content as part of the system. An improvement of the client's status as a result of the care provided by the nurse is part of the end product of the nursing process system. Output consists of the client's health status when getting ready to go back into the environment. NOT: Excluding feedback from the client's family when forming the plan of care. Family input should be included in the nursing process. The feedback part of the system utilizes client outcomes to refine the plan of care. Family input is also a form of feedback in the system, as this information can augment the plan of care. Making a nursing diagnosis of fluid retention related to heart failure as evidenced by pitting edema. Creating a nursing diagnosis is part of the nursing process, but a medical diagnosis cannot be used as part of it. Heart failure is a medical diagnosis. Assessing a pressure ulcer and then implementing regular position changes. The nursing process goes in order of assessment, formulation of a nursing diagnosis, planning of care, implementation of the plan, and evaluation. Assessment of a pressure ulcer and then implementing position changes skips the steps of forming a nursing diagnosis and creating a plan of care. Steps should be done in order to achieve best outcomes.

Root Cause Analysis (RCA)

The nurse manager should evaluate the process and circumstances as a whole before determining solutions. A root cause analysis (RCA) is a method of evaluating a problem and determining its cause. It is often used when an adverse event results in serious harm to a client, but it can also be used when there are safety concerns related to client care and when improvement is needed in the care provided. By using RCA, the manager is able to determine and specifiy what the problem is, determine what factors are in place that help to precipitate the problem, and develop a plan of action that will help to prevent future occurrence of the same problem. A nurse manager audits charts on a busy medical-surgical unit. The audit reveals a pattern of incident reports with late medications during the lunch hour. Which actions does the manager take? Select All That Apply Review the procedure for client coverage during staff lunch Review the procedure for client coverage during staff lunch. Determine the number of client medications during lunch hours Determine the number of client medications during lunch hours. Review the procedure for staff scheduling during lunch hours It is necessary to determine how lunch assignments are made for staff lunches as a part of the analysis of the cause of the problem. NOT: Instruct staff to schedule lunch after client lunch hours The nurse manager should not mandate staff lunches be delayed but should instead seek a solution that will meet client and staff needs. Request healthcare providers schedule medications outside of lunch hours The nurse manager should not request that healthcare providers change the medication schedules, as some medications are required to be administered with meals.

Priority assessment

The nurse's priority is assessment of the client. In order to determine the priority of care, the nurse must first assess. Notification of the client's family and review of labs and vital signs occur after the client has been assessed. A nurse cares for a client who is postoperative for a spleen repair. What is the nurse's priority action? Perform a physical assessment of the client. The nurse's priority is to assess the client. The client is post-op spleen repair, during which the client likely had a large amount of bleeding. The nurse observes the trend in vital signs and quickly assesses the client in order to determine the priority of care. NOT: Update the client's family regarding the client's condition. The nurse updates the client's family regarding the client's condition, but this is done after the nurse assesses the client. Review the client's most recent lab results. It is important for the nurse to review the client's most recent lab results, but this is done after the nurse assesses the client and determines the priority of care. Examine the overall trend of vital signs. The nurse examines the trending of the client's vital signs, but the nurse must first assess the client and then examine and evaluate the results.

Team Model of Nursing

The team model of nursing evolved from functional nursing. Functional nursing involves the assignment of tasks to registered nurses (RNs), practical nurses (PNs), and unlicensed assistive personnel (UAPs) on a particular unit. Team nursing, on the other hand, involves assigning a team nursing leader under whom a team of personnel work to provide total nursing care to a client. A charge nurse works on a nursing care unit that uses the team nursing model of care. Which action by the charge nurse is specific to this approach? Assigning a nurse leader to supervise client care activities The team nursing approach involves assigning a nurse team leader under whom other nursing and assistive personnel work. As a team, the group provides total nursing care to the client. NOT: Distributing client needs into tasks assigned to registered nurses, practical nurses, and unlicensed assistive personnel This is not unique to team nursing and best describes the functional nursing model of care. Delegating all vital sign measurements to the unlicensed assistive personnel This is not unique to the team approach of nursing and best describes the framework of the functional nursing model, in which tasks are assigned, versus the team model, in which total care is assumed under a team. Ensuring client tasks are properly delegated to the correct personnel Proper delegation and assignment are not unique to the team nursing approach, and client task delegation is a core feature of the functional model of care. It is not unique to the team nursing approach.

Case Management Model

The ultimate purpose of case management is cost-effective client quality outcomes. Increased hospital revenue, decreased chronic disease rates, and increased nurse satisfaction are not the primary benefits of the case management model. A nurse executive speaks to community stakeholders regarding the importance of client case management services. How does the nurse explain the primary benefit of case management? Cost-effective quality outcomes Case management is focused on achieving client outcomes within effective time frames, using available resources. This ultimately leads to cost-effective quality outcomes. NOT: Increased satisfaction of nurses Effective collaboration that occurs with case management may increase nurse satisfaction, but this is not the primary benefit of case management. Cost-effective hospital revenue Case management does focus on cost-effective strategies, but these strategies are patient-oriented quality outcomes and are not focused on hospital revenue. Decreased chronic disease Client case management focuses on the individual needs of the client being treated. Health promotion and maintenance are not common roles the nurse case manager assumes. Case management is focused on achieving client outcomes while maintaining cost-effective care. There are various sub-specialities of case management, including utilization review, risk management, and performance improvement, among others. Utilization review is a type of case management in which the nurse acts to carefully review the management and medical necessity of various resources for the client's care. Evaluating client satisfaction surveys is a role that nurses working in performance improvement assume. Nurse risk managers work to prevent situations that can result in losses or liability. A nurse case manager assumes the role of utilization review for a client's care. Which action by the nurse demonstrates this specific role? Evaluating the medical necessity of the client's care Utilization review is a type of case management in which the nurse acts to carefully review the management and medical necessity of various resources of the client's care. NOT: Evaluating deviations from client critical care pathways Evaluation of critical care pathways is the role the nurse risk manager assumes. Evaluating client satisfaction survey scores Evaluation of client satisfaction survey scores is a role that nurses in performance improvement assume. Evaluating client care data related to hospital compliance Evaluation of client care data as it relates to hospital compliance is a role that the nurse risk manager assumes.

Theophylline (Aminophylline)

Theophylline is a xanthine that may be used in the treatment of acute exacerbation of asthma. This drug must be closely monitored in order to ensure therapeutic range and reduce the risk of toxicity. The normal therapeutic range for an adult client is 5-15 mcg/mL. A trough is performed just before the administration of a drug to determine the lowest concentration of the drug in the client's system and to guide the health care provider in adjusting the client's dose. If the trough is out of range, the nurse notifies the health care provider prior to administering the drug. The client's chest radiography indicates the client has pneumonia. Clients with pneumonia usually need supplemental oxygen in order to maintain adequate blood oxygen levels. However, these clients should not have high-flow oxygen unless needed and evidenced by vital signs or arterial blood gas findings. A nurse cares for a client with an acute exacerbation of asthma. Prior to administering the scheduled 0800 theophylline dose, the nurse reviews the client's health record. What is the nurse's priority action? (See exhibit.) View Exhibits--> 0700 trough: 4mcg/mL (Therapeutic range: 5-15 mcg/mL) --> need to increase dosage: Notify the health care provider of the result. The client's trough level is sub-therapeutic, and the client's dose may need to be changed. The nurse notifies the health care provider regarding the results. NOT: Administer high-flow oxygen via a non-rebreather mask. The client's chest radiography suggests that the client has pneumonia. However, there is no indication in the exhibit that the client has a decreased blood oxygen level (hypoxemia). Because of this, the nurse does not apply high-flow oxygen via a non-rebreather mask. Administer the medication as prescribed. The client's trough level is lower than the therapeutic level of theophylline (5-15 mcg/mL). The dose may need to be adjusted, and the nurse should not administer the dose until the health care provider has seen the trough results. Wait for dosing advice from the pharmacist. Though the pharmacist adjusts the client's dose, it is based on the health care provider's prescription. This is not the priority nursing action.

Novice nurse

Though novice nurses have the same scope of practice as experienced nurses, the novice nurse may not have the advanced assessment skills required for various clinical situations. Clients with potential cardiac, gastrointestinal, or postoperative complications may not be best assigned to the novice nurse. Novice nurses should be allowed to care for these clients, but new nurses need an experienced nurse to guide nursing actions. A charge nurse makes assignments for the shift. Which client is best assigned to the novice nurse? A client with anemia who reports mild shortness of breath A novice nurse may be assigned this client. Clients with anemia may report shortness of breath but may not be unstable. NOT: A client with positive cardiac enzymes who reports chest pain Although the client may be stable, a client with positive cardiac enzymes and chest pain may deteriorate quickly and may be too difficult for the novice nurse. Another assignment is more appropriate. A client with absent bowel sounds and a rigid abdomen The client may be experiencing complications of the gastrointestinal tract and may require advanced assessment skills, which the novice nurse may not have acquired yet. This is not the most appropriate assignment for the novice nurse. A client who reports muscle spasms and is post-total thyroidectomy Clients who are post-operative after a total thyroidectomy may have serious complications related to decreased calcium levels that may manifest as muscle spasms or tetany. This client is unstable and should not be given to the new nurse.

Transformational leadership

Transformational leaders inspire and motivate individuals. Transactional leaders command, punish, and reward individuals. Quantum leaders allow individuals to have information and processes previously known only to leaders. A nurse manager leads using concepts of transformational leadership. Which action does the nurse manager take? Encourage the unlicensed assistive personnel to attend nursing school. Transformational leaders inspire and motivate followers. NOT: Reward staff members for attending all unit meetings. This is an example of a transactional leader, not a transformational leader. Transactional leaders reward and punish, whereas transformational leaders support and motivate. Instruct on the correct steps of cardiopulmonary resusciation during a code. This is an example of a transactional leader, not a transformational leader. Transactional leaders give commands or orders and expect everyone to follow. This type of management style may be effective in emergency situations but often leaves staff members desiring more say in what goes on in the day-to-day of the job. Allow staff to self-schedule, including holidays. This is an example of quantum leadership, not transformational. Quantum leadership allows information and processes, previously allowed by managers only, to be available and used by all staff members.

Nurse Educator

While providing care to clients, roles of the nurse include provider, educator, advocate, leader, change agent, manager, researcher, collaborator, and delegator. In the role of educator, the nurse is responsible for first assessing the client and evaluating what learning needs should be addressed during the time the nurse is providing care. The nurse also assesses what the client's learning styles are in order to determine a plan that will best meet the identified needs of the client. Education is one of the primary focuses of discharge planning, which begins with the first client encounter. Planning effective strategies tailored to each individual client ensures effective client education. A nurse cares for a client with a new diagnosis of diabetes. Which action by the nurse fulfills the role of an educator? Select All That Apply The nurse assists the client in understanding food choices that will meet the guidelines for this new diagnosis. This is an example of the nurse providing education to the client regarding a change in diet that is necessary with the new diagnosis of diabetes. The nurse instructs the client on the use of insulin at home after performing finger-sticks for glucose readings. This is an example of the nurse providing education to the client regarding needed dosage of insulin due to set glucose levels. NOT: The nurse notifies the healthcare provider of the client's lack of understanding regarding the new diagnosis of diabetes. This is an example of the nurse advocating for the client by having the healthcare provider give the client additional information regarding the diagnosis. The nurse instructs the unlicensed assistive personnel to perform a finger-stick prior to the client eating lunch. This is an example of the nurse delegating responsibility to an appropriately trained individual for completion of tasks needed for client care. The nurse contacts the case manager and requests assistance for the client in obtaining needed supplies. This is an example of the nurse advocating for the client by making needs known to the case manager, who can provide assistance for obtaining needed supplies.

Unlicensed Assistive Personnel (UAP) Delegation

Delegation involves the nurse passing the responsibility of completion of a task to another individual whose scope of practice includes the task. The nurse who delegated the task still remains accountable. The nurse first assesses and determines priority needs and eligible staff for completion of the task. In order to delegate, nurses need to be aware of the scope of practice of individuals to whom the nurse is delegating. The nursing process cannot be delegated. A nurse cares for several clients on a busy medical-surgical unit. Which tasks does the nurse delegate to the unlicensed assistive personnel (UAP)? Select All That Apply Assisting a client post-vaginal hysterectomy with perineal care Perineal care is within the scope of practice for a UAP. Obtaining a clean catch urine specimen for a drug screen Obtaining a urine specimen by clean catch is within the scope of practice for a UAP. Performing range-of-motion exercises for an immobile older adult client Range-of-motion exercises are within the scope of practice for a UAP. NOT: Changing the dressing of a client with a below-the-knee amputation A dressing change should be completed by a practical nurse or a registered nurse. Performing tracheostomy suctioning for a client with secretions Tracheostomy suctioning should be performed by a practical nurse or a registered nurse. Some UAP's are trained for a specific unit....? They can do FSBG and Dip Client Urine for Ketones, if they are trained...? Unlicensed personnel should be delegated tasks that are routine, unchanging, and have expected outcomes. Certain technical skills can be taught and performed by UAP after verification of training per facility policy. Client communication and assistance with eating are within the scope of practice of unlicensed assistive personnel, but the nurse needs to follow up if an after-meal insulin dose is needed, based on the carbohydrate count of the meal. A nurse should perform assessment, client education, and medication administration. A nurse cares for a client admitted with a diagnosis of diabetes. During admission, which tasks does the nurse delegate to the unit trained unlicensed assistive personnel (UAP)? Select All That Apply Finger-stick for glucose monitoring The UAP can perform glucose finger-stick testing with proper training. Delivery of diabetic 1,800-calorie tray The UAP can deliver a dietary tray to a client. Dipping client urine for ketones The UAP can dip urine for ketones with proper training. NOT: Explanation of the symptoms of hypoglycemia The nurse must provide education related to symptoms of disease. Administration of ordered insulin The nurse must administer medication. Delegation and supervision are important skills the nurse must master. Unlicensed assistive personnel (UAPs) may assist clients with positioning and in activities of daily living (ADLs). However, UAPs are not able to implement medication prescriptions, instruct, or demonstrate techniques or therapies to the client. These actions should only be performed by the nurse. A nurse cares for a client with chronic obstructive pulmonary disease (COPD). Which task does the nurse delegate to the unlicensed assistive personnel (UAP)? Positioning the client's head of bed at 30 degrees Assisting clients with positioning is within the scope of practice for the UAP, and this is an appropriate delegation. NOT: Instructing the client on the use of an incentive spirometer Instruction is an action that can only be performed by the nurse, not the UAP. Teaching is a task that is not delegated to the UAP. Demonstrating to the client the proper way to perform pursed-lip breathing Demonstration requires advanced training and is performed by the nurse only. Teaching is a task that is not delegated to the UAP. Increasing the client's oxygen as needed during ambulation Implementing health care provider prescriptions regarding medicine or oxygen therapy is not in the scope of the UAP. This task requires client assessment, something only the nurse can perform. Delegation is transferring responsibility for the performance of an activity or task while retaining accountability for the outcome. The nurse needs to be aware of the tasks that can be delegated as outlined by the Nurse Practice Act of each state.Client teaching and steps of the nursing process, which include assessment, diagnosis, planning, and evaluation, cannot be delegated, as they require nursing judgment. The nurse needs to address the five rights of delegation with each delegated task: right task, right circumstance, right person, right direction/communication, right supervision/evaluation. The nurse cares for a client admitted with diabetic ketoacidosis (DKA). The client has been diagnosed with type 1 diabetes mellitus. Which task is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Obtain blood glucose readings as prescribed. UAPs trained to obtain blood glucose readings can be delegated this task. The nurse is responsible for being aware of the client's glucose levels and acting appropriately based on the data. NOT: Assess the client's alertness and orientation. Assessment is part of the nursing process and should not be delegated to the UAP. Observe the client performing blood glucose testing. Blood glucose testing is an essential skill needed to manage type 1 diabetes mellitus. Observing the client's ability to perform the skill requires nursing judgment and should not be delegated to the UAP. Educate the client about subcutaneous injections. Client teaching is the responsibility of the nurse and should not be delegated to the UAP. Delegation involves the nurse passing the responsibility of completion of a task to another individual whose scope of practice includes the task. The nurse who delegates the task still remains accountable. The nurse first assesses and determines priority needs and eligible staff for completion of the task. In order to delegate, nurses need to be aware of the Nurse Practice Acts in the location of practice and scope of practice of individuals to whom they are delegating. The nursing process cannot be delegated. A new nurse receives a report on their daily assignment. After completing assessments and reviewing the required care, which tasks does the new nurse appropriately delegate to the unlicensed assistive personnel (UAP)? Select All That Apply Documenting breakfast intake for each client The UAP can collect a client's meal tray and document intake. Ambulating a 1-day postoperative client. The UAP can assist a client with ambulation. Emptying an indwelling catheter urine collection bag The UAP can empty a foley catheter bag and document output. NOT: Irrigation of a nasogastric tube Irrigation of a nasogastric tube must be performed by a nurse. Evaluating pain level after medication Assessment of pain must be performed by a nurse. UAP may assist in a variety of direct client care activities, like taking vital signs, performing range-of-motion exercises, bathing, providing catheter care, bed-making, and feeding patients who cannot feed themselves. Tasks that may be delegated to UAP are those that are regularly recurring in the care of clients according to established steps and have a predictable outcome. Tasks delegated to UAP may not involve ongoing assessment, interpretation, or decision-making that cannot be separated from the actual tasks. Though facility policy may vary, UAP may be trained to obtain urine specimens, give enemas, and perform blood glucose tests if allowed at that facility. The UAP must be trained per the facility policy with documentation of training prior to being allowed to complete tasks. A newly hired unlicensed assistive personnel (UAP) who performed glucose finger-sticks at a former place of employment shadows a nurse on the unit of hire. The UAP is scheduled for unit-specific training next week. Which action does the nurse take? Have the UAP observe performance of finger-sticks and document in employee training log. This allows the UAP an opportunity to observe how finger-sticks are performed per facility policy. NOT: Waive the unlicensed assistive personnel's need for training due to previous experience and allow fingersticks without supervision. The unlicensed assistive personnel should be trained according to facility policy. Allow the UAP to perform all of the scheduled finger-sticks with supervision. The UAP must first be trained in completion of finger-sticks per facility policy. Ask another nurse to teach the UAP how to perform finger-sticks per unit policy. It is not necessary to ask another nurse to train the UAP, because training is already scheduled.

discharge readiness

Evaluation of discharge readiness is an important skill for nurses to master. A client who is post-op from an uncomplicated surgery with manageable pain is a good candidate for discharge. Clients with unstable chronic conditions, traumatic injuries, and early labor symptoms are not candidates for discharge. The emergency department (ED) nurse evaluates discharge readiness for several clients. Which client does the nurse determine is most appropriate for discharge? A client who is 24 hours post-cholecystectomy with 4/10 pain and positive bowel sounds This client is stable, with manageable pain and return of bowel sounds, indicating that the bowel is working. Although the client recently had surgery, this client is 24 hours post-op and is stable enough for discharge. This client is most appropriate for discharge. NOT: A client who briefly lost consciousness from a fall from a ladder one hour ago and has vomited A loss of consciousness and vomiting may indicate a potentially life-threatening brain injury, especially in a client with a history of trauma (such as a fall from the ladder). This client is critical with life-threatening injuries and is not a candidate for discharge. A client with heart failure who gained 3 lbs. (1.4 kg) in the last 24 hours and has coarse crackles Rapid weight gain of more than 2 lbs. (0.91 kg) in one day is of great concern for a client with congestive heart failure. This indicates rapid fluid increases and places the client at high risk for fluid overload. Additionally, crackles auscultated in the lungs indicate excess fluid. This client appears unstable and is not a good candidate for discharge. A multigravida client experiencing irregular and frequent contractions at 36 weeks' gestation Multigravida clients have had two or more pregnancies and are at greater risk for precipitous or preterm labor. This client should not be discharged without further evaluation due to the risk of labor.

Tracheostomy dislodgement

If a tracheostomy tube is accidentally dislodged, the nurse must immediately attempt to replace it. The nurse should first grasp the retention sutures or use a hemostat to spread the opening of the stoma. Next, the nurse inserts the obturator into the new tube, then inserts the tube into the stoma. Finally, the obturator is removed in order for the client to breathe and for air to move through the tube. Grasp the retention sutures. Insert the obturator in the replacement tube. Insert the tube into the stoma. Remove the obturator.

Interdisciplinary flowsheet

The interdisciplinary flowsheet is a document used for all disciplines caring for a client at any given time. This flowsheet may be a paper copy or part of the electronic health record. The purpose of this document is to increase efficiency, decrease duplication of work, reduce handoff time, and improve job satisfaction by promoting collaboration among all healthcare disciplines. Though the document is used to promote a collaborative work environment, it does not reduce the required documentation needed for the client. A nursing student asks a staff nurse the purpose of the interdisciplinary flowsheet in a client's chart. The nurse includes which statements when responding to the nursing student? Select All That Apply "It improves job satisfaction." The interdisciplinary flowsheet is a collaborative document used to improve communication and foster a collaborative work environment. An effective collaborative work environment has been shown to improve job satisfaction, because it fosters good communication and decreases frustration of duplication of work. "It reduces handoff time." The interdisciplinary flowsheet reduces handoff time, because all disciplines caring for the client document on one flowsheet. This reduces the handoff time and increases efficiency with reporting on the client's condition. "It increases efficiency." Having all disciplines document on one flowsheet increases efficiency in that everyone involved in the client's care knows where to document. This document may be a part of the electronic health record or a paper flowsheet. "It reduces duplication of work." One central flowsheet where multiple disciplines document reduces the duplication of work for all disciplines. NOT: "It reduces required documentation." Although the flowsheet is designed to improve efficiency of documentation, it does not decrease the required documentation. Certain documentation is required for all clients, despite having a collaborative charting flowsheet.

Practical Nurse (PN) -- what they can do

Roles and responsibilities of PNs vary by state and facility practice. Most commonly, PNs are not able to provide IV treatments or perform assessments. PNs are qualified to give oral meds, perform client care activities, and collect vital signs. A client is on neutropenic precautions. What role in client care would be appropriate for the practical nurse (PN)? Administer 500 mg oral Vancomycin. The PN is able to independently administer oral medications, help with client care (bathing, walking, eating, oral hygiene, toileting), and collect vital signs. NOT: Give IV 40 mg pantoprazole. All IV medications are administered by a registered nurse. Exceptions may exist where the PN acquires an IV certification. Screen visitors for communicable diseases. Screening visitors is a form of assessment, which must be reviewed by the registered nurse. Determine which isolation precautions to initiate. The registered nurse is responsible for all assessments of the client, although the PN and the unlicensed assistive personnel may collect data for the nurse regarding the assessment. Ultimately, determining which isolation precautions to initiate is up to the registered nurse. It is important for the RN to know and understand the scope of practice of the PN when delegating nursing actions to the PN. Complete assessments and formulation of nursing plans should be left to the RN to complete. PNs may auscultate breath sounds, use sterile technique to suction established tracheostomies, and administer ophthalmic medications. A practical nurse (PN) and a registered nurse (RN) are assigned a group of clients on a nursing care unit. Which actions does the RN delegate to the PN? Select All That Apply Administer ophthalmic medications. The practical nurse can administer ophthalmic medications using sterile technique. Auscultate a client's breath sounds. The PN may auscultate breath sounds and record and report these findings. In-depth, head-to-toe assessments should be performed by the RN only. Suction an established tracheostomy. PNs may use sterile technique to suction an established tracheostomy. If the client is unstable or requires in-depth assessment, the RN performs this action. NOT: Complete a client's admission assessment. The RN should perform the complete admission assessment because of its complex nature, and the implementation and initiation of the nursing plan should be performed by the RN only. Formulate the nursing care plan. The PN can contribute to the nursing plan but cannot formulate a new nursing plan. Delegation involves the registered nurse passing the responsibility of completion of a task another individual whose scope of practice includes the task. The nurse who delegated the task still remains accountable. The nurse first assesses and determines priority needs and determination of eligible staff for completion of the task. In order to delegate, registered nurses need to be aware of Nurse Practice Acts in the location of practice and scope of practice for individuals to whom the nurse is delegating. The nursing process cannot be delegated. Oxygenation is a priority issue as related to Maslow's hierarchy of needs and respiratory concerns. The client with oxygen needs requires immediate intervention. When a nurse is caring for a critical client, this client's needs should be addressed prior to the needs of another client. If the nurse is unable to attend immediately to the oxygen needs of another client, it will be necessary to delegate to an appropriate caregiver so that the oxygen needs can be addressed. A registered nurse provides care for a critically ill client and is unable to leave the client. A UAP obtains noon vital signs for another assigned client and reports the findings to the registered nurse. Which action does the nurse take? (See exhibit.) Select All That Apply View Exhibits Ask the PN to apply oxygen via nasal cannula at 2 L/min. The registered nurse can delegate administration of oxygen to the practical nurses as this is within scope of practice. NOT: Report to the second client's room and apply supplemental oxygen. The registered nurse should not leave the critical client, but should delegate management of the oxygen needs to another registered nurse or a practical nurse. Ask the UAP to apply oxygen via nasal cannula at 2 L/min. Applying oxygen is not within the scope of practice for the unlicensed assistive personnel. Complete care needs of current client, then assess second client's respiratory status. The second client's oxygen needs should be addressed immediately and not left for after the RN is able to assess the client. Report to the second client's room and assess respiratory status. The registered nurse should not leave the critical client, but should delegate management of the oxygen needs to another registered nurse or a practical nurse. According the the NCLEX-PN test plan, PNs perform the following: -Perform urinary catheterization -Administer drugs by the PO, IM, and subcutaneous or intradermal route -Give oxygen or other medications by inhalation, ear, eye, nose, or skin -Administer drugs by gastrointestinal or nasogastric tube -Monitor IV flow rate and may administer IV piggyback (secondary) medications With required training, the PN can administer IV medications after the first dose has been administered by an RN. Any client expecting to receive IV medications should be managed by the RN. Stable clients are appropriate assignments for PNs, because they are generally on PO medications or IV medications that have been first administered by an RN. Newly admitted clients require an assessment and frequent monitoring from the RN until they are determined to be stable, so they are not appropriate assignments for care management by the PN. A charge nurse assigns a practical nurse (PN) to six clients. The team includes a registered nurse (RN), a PN, and an unlicensed assistive personnel (UAP). Which actions by the RN are correct? Select All That Apply Instruct the UAP to obtain vital signs on all assigned clients at 0800 and 1200. It is within the scope of practice for UAP to obtain vital signs. Inform the PN of the need to measure hourly output from the chest tube. It is within the scope of practice for the PN to measure chest tube output. Instruct the PN to administer 0800 PO medications to all assigned clients. It is within the scope of practice for the PN to administer PO medications. NOT: Ask the PN to complete an assessment on the client with a new chest tube. It is the responsibility of the RN to complete an assessment on a client with a new admission or after a procedure. Observe the PN administering newly ordered IV pain medication to a client. It is the responsibility of the RN to administer first doses of IV medications. The RN must be mindful of appropriate delegation to various individuals working on the unit with the nurse. Assessment, planning, and evaluation should not be delegated to anyone other than the RN. Assistance with activities of daily living may be delegated to the UAP, not the PN. Observation of a client is within the scope of the PN and may be delegated as appropriate. A registered nurse (RN) works with a practical nurse (PN) and unlicensed assistive personnel (UAP) to provide care for a client with emphysema and ineffective airway clearance. Which task is best assigned to the PN? Observe the client's technique of airway clearance activities. Observation is within the PN's scope of practice. This is an appropriate delegation. NOT: Assist the client with activities of daily living. This action can be delegated to the UAP, not the PN. Evaluate the efficacy of the nursing care plan. Planning and evaluating the nursing care plan should be performed by the RN, not the PN. Assess the client's knowledge of airway clearance techniques. PNs can gather data and report these findings, but assessment requires the advanced training of the RN. This action should not be delegated to the PN. Delegation involves the RN passing the responsibility of completion of a task to another individual whose scope of practice includes the task. The nurse who delegated the task still remains accountable. The nurse first assesses and determines priority needs and eligible staff for completion of the task. In order to delegate, RNs need to be aware of Nurse Practice Acts in the location of practice and scope of practice for individuals to whom they are delegating. The nursing process cannot be delegated. Even though tasks may be delegated to other nursing personnel, the RN is still legally accountable for all nursing care tasks. The registered nurse should never assume a delegated task has been completed. It is the RN's responsibility to ensure that care is given, so there must be follow-up after delegating a task. A registered nurse (RN) delegates administration of a pain medication to a practical nurse (PN). The client has surgical incision pain of 8/10. After completion of the task, which action does the RN take? Follow up with the PN within 30 minutes of delegating this assigned task. It is the responsibility of the registered nurse to follow up to ensure the delegated task has been completed. NOT: Ask another nurse to verify administration of the medication by the PN. Completion of the delegated task should be verified by the nurse delegating the task. Document the administration of the pain medication in the client's health record. The PN should document the medication administration when completed. Supervise the PN while administering the medication. It is not necessary for the RN to supervise the PN while administering the medication. Delegation involves the RN passing the responsibility of completion of a task to another individual whose scope of practice includes the task. The nurse who delegated the task still remains accountable. The nurse first assesses and determines priority needs and eligible staff for completion of the task. In order to delegate, RNs need to be aware of the scope of practice of individuals to whom they are delegating. The nursing process cannot be delegated. A registered nurse (RN) receives a new admission who requires immediate and ongoing attention. The RN requests assistance for tasks with the remaining assigned clients. Which tasks require completion by an RN or a practical nurse (PN)? Select All That Apply Insertion of an indwelling urinary catheter for a client unable to void. An indwelling urinary catheter should be placed by a PN or an RN. Cleaning and suctioning an endotracheal tube This is a task that must be performed by a PN or RN. Providing a client with instructions prior to discharge Client education is completed by a nurse. NOT: Assisting a client with ambulation in the hallway Unlicensed assistive personnel can assist a client with ambulation in the hallway. Obtaining vital signs on a 1-day post appendectomy client Unlicensed assistive personnel can obtain vital signs and report the findings to the nurse. According the the NCLEX-PN test plan, practical nurses perform the following: 1. Administer oral, IM, and subcutaneous medication 2. Perform urinary catheterization 3. Administer drugs by the PO, IM, and subcutaneous or intradermal route 4. Give oxygen or other medications by inhalation, ear, eye, nose, or skin 5. Administer drugs by gastrointestinal or nasogastric tube 6. Monitor intravenous (IV) flow rate and may administer IV piggyback (secondary) medications. With required training, the PN can administer IV medications after the first dose has been administered by a registered nurse. A registered nurse (RN) works with a practical nurse (PN) on a medical-surgical unit. Which tasks does the RN delegate to the PN? Select All That Apply Administer the first dose of ibuprofen 600 mg PO to a client for pain. The practical nurse can administer PO medications. Perform a urinary catheterization on a client unable to void. A practical nurse can perform urinary catheterization. Administer the third dose of cefazolin 2 g by IV piggyback. The practical nurse may administer IV piggyback (secondary) medications. NOT: Administer the first dose of ketorolac 30 mg IV to a post-surgical client. The first dose of an IV medication must be administered by a registered nurse. Initiate an IV infusion on a newly admitted client. Initiation of an IV infusion must be performed by a registered nurse. Unlicensed assistive personnel can perform many non-invasive tasks such as ambulation, activities of daily living, and the care of stable clients. Practical nurses (PNs) may do other invasive tasks, such as urinary catheter irrigation. PNs are not able to complete all tasks that registered nurses can, as they do not have the same knowledge base.When delegating, the nurse must follow the five rights of delegation: right task, right circumstance, right person, right direction and communication, and right supervision and evaluation. Responsibility always remains with the nurse as the licensed professional, even when tasks are delegated. Additionally, acts within the scope of practice for all healthcare providers may vary by state policy and should be the basis for delegation. A nurse cares for a client with a prescription for irrigation of an indwelling urinary catheter. The nurse knows this task can be delegated to which personnel? A practical nurse Irrigation of a urinary catheter is within the scope of practice for a practical nurse. NOT: The on-call urologist It would not be appropriate to delegate this task to someone with higher training such as a urologist. This task can be performed by other qualified personnel. An unlicensed assistive personnel Unlicensed assistive personnel may not irrigate a catheter, as it is not within their scope of practice to do so. A radiology technician Irrigating an indwelling catheter must be done by a PN or RN, as other personnel are not qualified to do such a procedure. A radiology technician does not have the necessary skills for this task. According the the NCLEX-PN test plan, PNs perform the following: 1. Perform urinary catheterization 2. Administer drugs by the PO, IM, and subcutaneous or intradermal route 3. Give oxygen or other medications by inhalation, ear, eye, nose, or skin 4. Administer drugs by gastrointestinal or nasogastric tube 5. Monitor intravenous (IV) flow rate and may administer IV piggyback (secondary) medications With required training, the PN can administer IV medications after the first dose has been administered by a registered nurse. Any client expecting to receive IV medications should be managed by the RN. Stable patients are appropriate assignments for PNs, because they are generally on PO medications or IV medications that have been first administered by an RN. Newly admitted clients require an assessment from an RN and frequent monitoring until they are determined to be stable and, therefore, are not appropriate assignments for care management by a PN. A charge nurse delegates assignments for the oncoming shift with a registered nurse (RN) and a practical nurse (PN). Which assignments are appropriate for the PN? Select All That Apply A toddler-aged client 1-day post-surgical repair for clubfoot This client can be appropriately managed by a PN as this is an established client and not a new admission requiring assessment and frequent monitoring. An adolescent client two days post-appendectomy This client is stable and can be appropriately managed by the PN. NOT: A newly admitted adult client wth congestive heart failure A newly admitted client requires assessment by an RN and, due to the diagnosis, requires frequent monitoring for the first few hours after admission. An older adult client transferred from critical care after extubation This is a new admission and requires assessment and frequent monitoring by the RN for the first few hours after admission. A young adult client with ovarian cancer admitted for chemotherapy A client receiving chemotherapy should be assigned to an RN due to administration of IV chemotherapy and associated IV medications. According to the NCLEX-PN test plan, PNs perform the following: 1. Urinary catheterization 2. Administration of drugs by the PO, IM, and subcutaneous or intradermal route 3. Administration of oxygen or other medications by inhalation, ear, eye, nose, or skin 4. Administration of drugs by gastrointestinal or nasogastric tube 5. Monitoring IV flow rate and administering IV piggyback (secondary) medications In some settings with required training, the PN can administer IV medications after the first dose has been administered by a registered nurse. A registered nurse (RN) delegates care to a practical nurse (PN) on a medical-surgical unit. The nurse manager rounds on the unit. Which action observed being performed by the PN would require the nurse manager to discuss appropriate delegation with the RN? Select All That Apply Assessment of a newly admitted client from the surgical recovery room Initial assessment of a newly admitted client must be completed by an RN. NOT: Administration of a first dose of IVPB cefazolin to a client with pneumonia The PN can administer IVPB (secondary) medications. Administration of oxycodone, two tabs PO for post-surgical pain management The PN can administer PO medications. Changing the abdominal dressing of a client with a wound drain three days post-surgery The PN can perform wound care such as dressing changes. Removing the staples from a back surgical incision prior to discharge home The PN can remove sutures or staples.

Priority of care

Determining the priority of care is essential for the registered nurse. When determining the priority of care among clients with acid-base imbalances, the nurse prioritizes care for those with complications first. Next, clients with high-risk medications are assessed second. Clients with referrals or requiring discharge instruction or teaching are assessed third. Finally, clients with acid-base imbalances with normal vital signs are assessed last.

float nurse assignments

Nurses who have floated from one unit to another must be given careful consideration for their assignments. A nurse trained in intensive care may struggle to care for a six-client assignment on a medical-surgical floor; an oncology nurse may not be well equipped to care for a full client assignment on an orthopedic unit; and the pulmonary floor nurse should not be expected to manage critically ill clients, if at all possible. Therefore, when the floor nurse (medical-surgical nurse) works on the ICU for a shift, this nurse should be assigned the most stable clients to ensure that care can be delivered safely and effectively. A nurse from the pulmonary unit is assigned to the intensive care unit (ICU) to fill a staffing need. Which client does the charge nurse assign to the pulmonary nurse? A client with a myocardial infarction scheduled for discharge to hospice within one day The client readying for discharge is relatively stable and is suitable for the pulmonary floor nurse to care for during this shift. The client would be under hospice care, and comfort measures are likely to be needed. NOT: A client with a tracheotomy performed twelve hours previously with fluctuating oxygen saturations The nurse from the pulmonary unit is uniquely able to manage a client with a tracheotomy. However, this client is in the ICU with unstable oxygen saturations and is better suited to a nurse with ICU training. A client with an acetaminophen overdose, oliguria, jaundice, and elevated liver function tests A client with an overdose of any kind is not suitable for the pulmonary floor nurse, if this can be avoided. This particular client also has renal and liver failure, which is expected to result in continued organ failure and intense care management. A client with a diltiazem continuous infusion for unstable angina and shortness of breath The pulmonary nurse should not be asked to manage a cardiac drip and an unstable cardiac client if this can be avoided. Proper assignments for all nursing staff are the responsibility of the charge nurse. Nurses often "float" to another unit and may not be familiar with various procedures and techniques. Nurses who are unfamiliar should be assigned stable clients who do not require special teaching or referral initiation. The charge nurse should not assign unfamiliar nurses to postoperative clients with complications, special teaching needs, or clients with specialized equipment, such as skeletal traction. A charge nurse makes assignments for the shift. Which client does the charge nurse assign to the nurse who has floated to the unit for the day? An older adult with chronic respiratory acidosis with an SpO2 of 89% Chronic respiratory acidosis may occur in conditions such as chronic obstructive pulmonary disease. It is not uncommon for a client with chronic obstructive pulmonary disease to have an SpO2 of 89%, and this client appears stable. This client would be an appropriate assignment for the floating nurse. NOT: An adult client with a new colostomy who is scheduled to be discharged tomorrow Although the client appears stable, a new colostomy requires extensive client teaching. This client should not be assigned to an unfamiliar nurse who may not have the proper training on this or who may not know how to initiate the proper referrals for this client. A pediatric client in skeletal traction with stable vital signs Although the client has stable vital signs, a client in skeletal traction should not be assigned to a nurse who may be unfamiliar with the care involved for the client. This is not an appropriate delegation. A young adult client recovering from an open appendectomy who is febrile This client does not appear stable and may have a postoperative infection. This client should not be assigned to a nurse who may be unfamiliar with these situations.

Osteoporosis

Osteoporosis occurs when the body loses too much bone, makes too little bone, or both. Bones with osteoporosis are porous and have a honeycomb appearance. The bones are weak and at an increased risk for breaks. Some risk factors for osteoporosis (age, gender, family history, and medical history) are not controllable. Other risk factors (diet, tobacco use, alcohol use, and exercise habits) can be controlled. The nurse performs a musculoskeletal assessment on a client. Which behavior increases the client's risk for osteoporosis? The client consumes 400 mg of calcium daily. Less than 500 mg of calcium per day is considered a risk factor for osteoporosis. Optimal calcium intake is 1,000 mg per day for adults under 50 years old and 1,200 mg per day for adults over 50 years old. NOT: The client drinks a glass of wine each evening. Consumption of more than two alcoholic drinks per day increases the risk of osteoporosis. The client runs for 30 minutes, three times per week. Weight-bearing exercises such as walking, running, jumping, dancing, and weightlifting are beneficial to the bones and reduce osteoporosis risk. The client has a cup of regular coffee each morning. Caffeine can interfere with calcium absorption, but drinking fewer than three cups of coffee per day does not put clients at increased risk for osteoporosis.

Referral process

The public health nurse should be familiar with the referral process in order to ensure that clients receive the appropriate care necessary. The process of referrals occurs in this order: intake, assessment, setting objectives or goals, searching for resources, and ensuring these resources are available to the client.

client care assignments

Using the safety-first framework, the charge nurse recognizes that the acuity of clients needs to be considered when making client assignments as well as nurse-to-client ratios. Depending on client acuity, the charge nurse determines client care assignments for nurses assigned to each unit. A charge nurse on a pediatric unit receives a call regarding a new admission from the emergency department. Which current client assignment(s) would allow a nurse to receive an additional admission? Select All That Apply A client who has completed a blood transfusion A client who has completed a blood transfusion does not require frequent monitoring. This nurse would be free to take an additional assignment. A client recently discharged and waiting for a ride The nurse who has a client who has been discharged and is waiting for a ride is free to take an additional client assignment. NOT: A client requiring a complex dressing change A client requiring a complex dressing change will demand time from the nurse. This nurse may not have time to take an additional assignment. A client receiving a first round of chemotherapy The administration of a first round of chemotherapy requires frequent monitoring. This nurse will not have time to take an additional assignment. A client with multiple gastrointestinal bleeding sites A client with multiple gastrointestinal bleeds will require frequent monitoring. This nurse may not have time to take an additional assignment.

Anthrax powder

Anthrax is an infection caused by the bacterium Bacillus anthracis. It can be encountered through working with animals and can cause infections of the skin or respiratory tract. When used in bioterrorism, an aerosolized powder is used and is highly infectious. In addition to preventing the spread of the spores and protecting him- or herself and people in the environment, the nurse also consults guidelines about agencies requiring notification of possible anthrax exposure. A client arrives at the hospital after exposure to possible anthrax powder. What actions does the nurse take when first encountering the client? Select All That Apply Put on a gown, gloves, goggles, and N95 respirator. The nurse must protect him- or herself from from exposure to the anthrax spores that may be present on the client. Gown, gloves, goggles, and fit-tested respirator are all recommended by the Centers for Disease Control. Treat the client's clothing as hazardous material. The anthrax spores are easily carried on clothing and need to be handled per hazardous material protocols. Place the client in isolation room with negative pressure. While the client removes clothing, having negative pressure in the isolation room reduces the risk that the spores can be transmitted out of the room. NOT: Tell the client to wait in the waiting area, away from others. The client should not be allowed to spend any time in a public area prior to decontamination. Place mask on the client to prevent droplet transmission. Anthrax is not transmitted via droplet from person to person. Only the spores that may be present on the client pose a risk.

Inappropriate nursing behavior

It is not completely incorrect to confront the nurse, to alert the supervisor, or to continue to observe the nurse, but the best action by the nurse is to alert the immediate hiring manager with the observations and to allow the manager to deal with the employee. If, however, the nurse observes behaviors that immediately endanger others, such as the nurse falling asleep while delivering medications or actively taking substances, the nurse must intervene until the manager or supervisor can assist. A staff nurse working the day shift notices the charge nurse behaving in a manner consistent with intoxication. Which action is best for the staff nurse to take? Call the unit manager to describe the situation and observations. The unit manager is immediately responsible for the nurse's behaviors and for handling it. If the manager needs to call the supervisor or others to assist, that is the manager's decision. NOT: Notify the nursing supervisor that the charge nurse may be impaired. The nurse should notify the nursing supervisor, but the clients on the unit require immediate protection. Watch the charge nurse throughout the day and note specific behaviors. Monitoring a nurse who may be intoxicated places clients and others at risk. Ensure the charge nurse does not administer medications to any clients. The nurse is not in a place to confront the potentially intoxicated nurse. This is out of the nurse's role.

Chest Tube Care- Some Key Points

Observe for tiding or bubbling in water seal chamber- if not "tidaling" or bubbling the system is blocked or lungs are reexpanded Tidaling is the fluctuation of water with respirations (rising with inspiration, falling with expiration. The opposite will occur when patient is mechanically ventilated) • Monitor the patient and system frequently o VS o LS o Chest wall and dressings o Observe and mark drainage • CDB frequently- Q1H • Encourage ROM of the Effected Side • Turn and Position for Comfort and Lung Reexpansion • Assess and Control Pain • Bubbling should be intermittent o Continuous bubbling indicates an air leak • Check all connections • Temporary clamping may be used to determine air leak location if allowed by surgeon/facility Note: Bubbling in the (wet) suction control chamber indicates the suction is working- gentle bubbling is sufficient • Do not strip or routinely milk chest tubes Causes increased pressure and trauma Chest tubes and closed drainage systems require the nurse to think critically about priorities of care. A continuous bubbling in the water-seal chamber of the closed drainage system should be addressed first, as this may indicate an air leak and a potential complication of the therapy. Reports of pain and mild drainage do not take priority when planning care for clients with chest tubes. Additionally, chest tube dressings should be changed per hospital policy and do not need to be changed daily unless required due to heavy saturation of fluid or blood. A nurse cares for a group of clients with chest tubes, all connected to suction via a closed drainage system. Which situation does the nurse address first? Continuous bubbling in the water-seal chamber Continous bubbling in the water-seal chamber of the chest tube drainage system may indicate an air leak and should be assessed first. NOT: Measured 15 mL/hr. of serosanguineous fluid 10-15 mL/hr. drainage of serosanguineous fluid is within the acceptable range of chest tube drainage and does not take priority. Insertion site dressing dated yesterday Chest tube insertion site dressings should be changed according to hospital policy and do not need to be changed daily. This is not the priority of care. Reports of pain at the insertion site Though it is always important for the nurse to assess a client's pain, pain at the chest tube insertion site is expected. The nurse assesses this client, but this does not take priority. Dislodgement of a chest tube is a life-threatening emergency. The nurse must first cover the insertion site with a sterile, non-occlusive dressing, ask another nurse to notify the healthcare provider, stay with the client and monitor vital signs, and observe for symptoms of tension pneumothorax. This develops when air is trapped in the pleural cavity which compresses the lungs and causes there to be a decreased venous return to the heart. Symptoms include chest pain, SOB, rapid breathing, and a rapid heartbeat and can quickly develop into shock.

Primary peritonitis

Primary peritonitis occurs when the peritoneal fluid becomes infected and is typically seen with ascites or cirrhosis. Secondary peritonitis occurs from a foreign body in the peritoneal cavity, abdominal organ rupture, or severe genitourinary infections. The treatment for secondary peritonitis is quite different from primary peritonitis, as secondary peritonitis typically requires surgical intervention. Primary peritonitis typically requires antibiotics. The client with primary peritonitis asks the nurse, "What caused my infection?" The nurse answers the client with what response? "It is an infection of peritoneal fluid associated with cirrhosis and ascites." Primary peritonitis occurs when blood-borne organisms enter the peritoneal cavity, such as with ascites, producing an excellent liquid environment for bacteria to flourish. NOT: "Primary peritonitis is seen with inflammation of the pancreas due to infection." Chronic pancreatitis may develop from inflammation of the pancreas and ducts. While inflammation of the pancreas may occur with primary peritonitis, the main teaching point of primary peritonitis is that it is an infection of the peritoneal fluid seen with cirrhosis and ascites. "Primary peritonitis occurs when a foreign object enters the peritoneal cavity." Secondary peritonitis occurs when abdominal organs perforate or rupture and release their contents into the peritoneal cavity, such as with a ruptured appendix or perforated ulcer. "When an abdominal organ perforates, primary peritonitis may occur." Secondary peritonitis occurs when abdominal organs perforate or rupture and release their contents into the peritoneal cavity, such as with a ruptured appendix or perforated ulcer.

Delegation Process

Various steps make up the delegation process: Assessment and planning: The first step of the delegation process is assessing and planning the delegation based on the individual client's needs, the UAP's training, and available resources. Communication: The second step of the delegation process is to communicate directions such as unique client requirements and clear directions about what to do, what to report, and when to ask for assistance. Determine supervision: The third step in the delegation process is to determine the supervision level needed for the task. Also known as surveillance, this step also includes follow-up to changing needs. Evaluation: The final step in the delegation process is the evaluation and feedback step, which determines the effectiveness of the delegation. Using these steps allows the nurse to effectively delegate in order to ensure client safety and appropriateness of care. These steps are are discussed in more detail within the Joint Statement on Delegation by the ANA and NCSBN.

Delirium

Delirium is an acute mental disorder that can occur among hospitalized clients. It often presents within the first 48 to 72 hours of admission. Delirium is characterized by confusion, disorientation, and restlessness. The condition often reverses when the underlying physical condition is treated. The nurse educates the family of a client who is experiencing delirium. Which statement accurately describes delirium? "Delirium symptoms are often worse in the evening and night." Clients with delirium are often labeled with "sundown syndrome" because the symptoms worsen at night. NOT: "Delirium indicates the client is developing dementia." Delirium is an acute disturbance of consciousness accompanied by a change in cognition. It is not caused by a preexisting or evolving dementia. "Delirium is a condition that develops over months." Delirium develops over a short period of time, usually hours or days. "Delirium is a condition that is only seen in older adults." Delirium is most common in older adults but can be found in clients of all ages.

IV Catheter removal

Care should be taken when removing an IV catheter so that no breakage occurs to the catheter. If resistance is felt, force should not be applied to remove it, as this can cause the catheter to break off into circulation and travel to the heart or lungs and cause serious complications.If the catheter tip appears to be cut off, this would be an abnormal and serious finding. The missing piece of the IV catheter may remain inside the client's body and should be removed. The healthcare provider would need to be notified. If the catheter tip appears cut off, it is possible that the tip broke apart, possibly during removal. This is significant because the broken piece may embolize, causing life-threatening complications. A client is ready for discharge, and the nurse removes the IV. Which finding is significant when assessing the integrity of a discontinued IV catheter? The catheter tip appears cut off. If the catheter tip appears cut off, it is possible that the tip broke apart, possibly during removal. This is significant because the broken piece may embolize, causing life-threatening complications. NOT: The catheter tip contains blood. The catheter tip may have blood in it after removal due to blood backing up into it. This is a normal finding. The IV site bruises after removal. Bruising from the IV site may occur, especially in clients with fragile veins. If the site appears raised from blood leaking under the skin, pressure should be applied to prevent any further leaking into the tissue. The catheter is slightly bent at the hub. If the catheter is slightly bent, this is not necessarily cause for concern. Care should be taken to ensure the catheter appears intact upon removal of it.

American Nurses Association (ANA)

The ANA has established formal training for nurse advocates. An American Nurses Advocacy Institute (ANAI) fellow acts to educate colleagues on various political issues, establishes priorities, recommends strategies, and acts as counsel to a state nurses' association. A nurse advocate completes the training to become a fellow with the American Nurses Association (ANA). Which roles does the nurse assume? Select All That Apply Act as counsel to the state nursing association. The nurse advocate fellow acts as counsel to the state nurses' association in order to recommend, establish, and promote various policies. Recommend strategies to advance a policy. The nurse advocate fellow recommends strategies to state nurses' associations on advancing various policies that impact nurses or their clients. Assist in establishing legislative policies. As an American Nurses Advocacy Institute fellow, the nurse advocate works with state nurses' associations in order to establish legislative policies. Educate colleagues about political realities. As an American Nurses Advocacy Institute fellow, the nurse educates colleagues about political realities in order to ensure nurses are aware of what is happening on the political front of nursing and healthcare. NOT: Pass various laws endorsed by the ANA. As advocate, the nurse does not single-handedly pass a law. This is achieved by majority vote and is part of the legislative process.

Prioritizing nursing interventions

When establishing care in a life-threatening situation, the nurse must remember airway, breathing, and circulation. Obtaining the vital signs takes priority over obtaining the client's past medical history, assessing the client's pain, and positioning the client in a comfortable position. A nurse cares for a client who reports sudden mid-sternal chest pain. Which nursing intervention takes priority? Obtain the client's vital signs. Mid-sternal chest pain may indicate cardiac compromise, such as myocardial infarction. This is a life-threatening situation, and the client's vital signs must be obtained before additional care in order to determine the client's cardiovascular status and prioritize interventions. NOT: Ask the client to describe the pain. Asking the client to describe the pain is an appropriate nursing intervention, but the nurse should focus and prioritize the assessment, gathering more data about cardiac output and circulatory status prior to assessing pain characteristics. Place the client in a position of comfort. Placing the client in a position of comfort is an appropriate nursing intervention, but this is not the priority of care and is not the initial action of the nurse. Review the client's past medical history. The client is experiencing a life-threatening situation, and reviewing the client's past medical history does not best help the client. The nurse will eventually review the past medical history, but this is not the nurse's priority.

acute renal failure (ARF)

A client with acute renal failure and oliguria is at risk for complications related to fluid overload. Strict monitoring of fluid intake and output should be done to avoid further issues. The client should be assessed for signs of worsening fluid overload such as decreased urine output, distended neck veins, dependent edema, rapid and shallow respirations, decreased oxygen level, and elevated blood pressure. A nurse prepares a nursing care plan for a client with acute renal failure, oliguria, and fluid volume excess. Which intervention does the nurse include in the care plan? Assess fluid intake and output each shift. An important nursing intervention is to accurately record and monitor the client's daily fluid intake and output. Monitoring intake and output helps prevent complications associated with fluid overload by recognizing a potential problem before it forms into a complication. NOT: Encourage PO fluid intake and record. Clients with fluid volume excess are usually placed on a PO fluid intake restriction, so encouraging increased PO fluid intake is not appropriate. Measure the client's weight on admission and prior to discharge. A client with fluid volume excess will require daily measuring and recording of weight to monitor whether the fluid volume excess is decreasing in response to interventions, not just on admission and discharge. Decrease daily IV fluid intake based on PO intake. IV fluid intake must be included in the overall intake and output totals that are documented daily, but decreasing IV fluid intake must be managed in collaboration with the healthcare provider and not implemented by the nurse without a prescription.

Post-op ambulation

Nurses should know which goals are appropriate for clients at each phase of recovery after surgical procedures. Assisting clients to meet appropriate goals will help the progression of healing and prevent complications after surgery.Ambulation should be performed early to help reduce the risk of developing postoperative complications such as respiratory compromise or a blood clot. Constipation may be experienced, especially with administration of opioid pain medications. Assessment should be done to ensure the client is not experiencing any bowel-related complications. The healthcare provider should be notified of any potential signs of paralytic ileus such as a distended abdomen, abdominal discomfort, vomiting, or absence of passage of flatus or stool after 3 to 5 days.After the initial post-operative healing period, it is more appropriate to encourage the client to eat a high-fiber diet and nutrient-dense foods to assist with bowel elimination and wound healing rather than a diet high in saturated fat.The client should be up within the first 12 hours after surgery if no complications are present. Assisting the client to ambulate to the bathroom also gives the client the opportunity to attempt urination or bowel elimination after surgery.