Exam 4 Delegation & Assignment

During care of patients, what is the MOST important precaution for preventing transmission of infection? A. Wearing face and eye protection during routine daily care of the patient. B. Wearing non-sterile gloves when in contact with body fluids, excretions and contaminated items. C. wearing gown to protect the skin and clothing during patient care activities likely to soil clothing. D. Hand washing after touching fluids & secretions, removing gloves, and between patient contacts.

. d. Hand washing is the most important factor in preventing infection transmission and is recommended before and after the use of gloves by the Centers for Disease Control and Prevention for all types of isolation precautions in health care facilities.

A patient with advanced AIDS has a nursing diagnosis of impaired memory related to neurologic changes. In planning care for the patient, what should the nurse set as the highest priority? a. Maintain a safe patient environment b. Provide a quiet, nonstressful environment to avoid overstimulation c. Use memory cues such as calendars and clocks to promote orientation d. Provide written instructions of directions to promote understanding and orientation

A All of the nursing interventions are appropriate for a patient with impaired memory, but the priority is the safety of the patient when cognitive and behavioral problems impair the ability to maintain a safe environment.

The unlicensed assistive personnel (UAP) tells the nurse that a patient who is receiving oxygen at a flow rate of 6 L per min by nasal cannula is reporting nasal passage discomfort. What intervention should the nurse suggest to the UAP to improve the patient's comfort for this problem? A. Humidify the patient's oxygen. B. Use a simple face mask instead of a nasal cannula. C. Provide the patient with an extra pillow. D. Have the patient sit up in a chair at the bedside

A. When the oxygen flow rate is higher than 4 L per min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Applying water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.

What is the most important nursing intervention for the prevention and treatment of pressure ulcers? a. using pressure-reduction devices b. repositioning the patient frequently c. Massaging pressure areas with lotion d. Using lift sheets and trapeze bars to facilitate patient movement

B. Relief of pressure on tissues is critical to prevention and treatment of pressure ulcers. Although pressure- reduction devices may relieve some pressure and lift sheets and trapeze bars prevent skin shear, they are no substitute for frequent repositioning individualized for the patient. Massage is contraindicated if there is the presence of acute inflammation or possibly damaged blood vessels or fragile skin.

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months of experience) floated from the surgical unit to the medical unit? a. A 58-year-old patient on airborne precautions for tuberculosis (TB) b. A 65-year-old patient who just returned from bronchoscopy and biopsy c. A 72-year-old patient who needs teaching about the use of incentive spirometry d. A 69-year-old patient with chronic obstructive pulmonary disease (COPD) who is ventilator dependent

C. A fairly new nurse should be assigned more stable and less complicated patients. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized and careful assessment and monitoring after the procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.

The nurse is initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should the nurse delegate to the unlicensed assistive personnel (UAP)? A. Teaching the patient about the importance of adequate fluid intake and hydration B. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed C. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake D. Encouraging the patient to take a deep breath, hold it for 2 seconds, and then cough two or three times in succession

C. UAPs can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic UAP. However, an experienced UAP could assist the patient with positioning after the UAP and the patient had been taught the proper technique. UAPs would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill and is within the scope of practice of the RN.

A patient identified as HIV antibody positive 1 year ago manifests asymptomatic HIV infection but does not want to start ART at this time. What is the best nursing intervention for the patient at this stage of illness? a. Assist with end-of-life issues b. Provide care during acute exacerbations c. Provide physical care for chronic diseases d. Teach the patient about immune enhancement

D. After a patient has positive HIV antibody testing and is in acute disease, the overriding goal is to keep the viral load as low as possible and to maintain a functioning immune system. The nurse should provide teaching regarding ways to enhance immune function (e.g., nutrition, vaccinations, rest and exercise, stress reduction) to prevent the onset of opportunistic diseases in addition to teaching about the spectrum of the infection, options for care, signs and symptoms to watch for, ways to prevent HIV spread, and ways to adhere to treatment regimens when ART drugs are initiated. The asymptomatic stage is too early for the other options.

Suctioning and Trach care: Role of LPN

For stable patients: • Determine the need for suctioning. • Suction the tracheostomy. • Evaluate whether patient status is improved after suctioning. • Provide tracheostomy care using sterile technique.

Role of Nursing Personnel Suctioning and Trach care: Role of Registered Nurse (RN)

For unstable patients: • Assess for the need for suctioning. • Suction the ET or tracheostomy tube. • Evaluate for adverse effects of suctioning such as dysrhythmias. • Evaluate whether patient status is improved after suctioning. • Maintain appropriate cuff inflation pressure at 20 to 25 cm H2O, or use minimal leak technique to maintain cuff pressure. • Assess tracheostomy and any retention sutures for evidence of complications (e.g., infection). • Replace the tracheostomy tube after accidental dislodgment. • Ventilate the patient with a bag-valve-mask device after accidental tracheostomy dislodgment if needed. • Assess swallowing ability and risk for aspiration. • Develop plan to avoid aspiration in a patient with a tracheostomy. • Teach patient and caregiver about home tracheostomy care.

Teamwork & Collaboration of Wound Care

In general, wound care for complex or non-healing wounds should be managed by the registered nurse (RN). State nurse practice acts vary in the wound care actions allowed by licensed practical nurses (LPNs) and unlicensed assistive personnel (UAP).

Suctioning and Tracheostomy Care

Licensed practical nurses (LPNs) may do suctioning and give tracheostomy care to stable patients. In patients who have acute airway problems requiring an ET or tracheostomy tube, these interventions should be done by the registered nurse (RN).

6. A 75-year-old patient who is breathing room air has the following arterial blood gas (ABG) results: pH 7.40, PaO2 74 mm Hg, SaO2 92%, PaCO2 40 mm Hg. What is the most appropriate action by the nurse? a. Document the results in the patient's record. b. Repeat the ABGs within an hour to validate the findings. c. Encourage deep breathing and coughing to open the alveoli. d. Initiate pulse oximetry for continuous monitoring of the patient's oxygen status.

a. Normal findings in arterial blood gases (ABGs) in the older adult include a small decrease in PaO2 and SaO2 but normal pH and PaCO2. No interventions are necessary for these findings. Usual PaO2 levels are expected in patients 60 years of age or younger.

8. A pulse oximetry monitor indicates that the patient has a drop in SpO2 from 95% to 85% over several hours. What is the first action the nurse should take? a. Order stat ABGs to confirm the SpO2 with a SaO2. b. Start oxygen administration by nasal cannula at 2 L/min. c. Check the position of the probe on the finger or earlobe. d. Notify the health care provider of the change in baseline PaO2.

c. Pulse oximetry is inaccurate if the probe is loose, if there is low perfusion, or when skin color is dark. Before other measures are taken, the nurse should check the probe site. If the probe is intact at the site and perfusion is adequate, an ABG analysis will be ordered by the HCP to verify accuracy, and oxygen may be administered, depending on the patient's condition and the assessment of respiratory and cardiac status.

23. What is a primary nursing responsibility after obtaining a blood specimen for ABGs? a. Add heparin to the blood specimen. b. Apply pressure to the puncture site for 2 full minutes. c. Take the specimen immediately to the laboratory in an iced container. d. Avoid any changes in oxygen intervention for 15 minutes following the procedure.

c. Samples for ABGs must be iced to keep the gases dissolved in the blood (unless the specimen is to be analyzed in <1 minute) and taken directly to the lab. The syringe used to obtain the specimen is rinsed with heparin before the specimen is taken and pressure is applied to the arterial puncture site for 5 minutes after obtaining the specimen. Changes in oxygen therapy or interventions should be avoided for 15 minutes before the specimen is drawn because these changes might alter blood gas values.

Which nursing interventions for a patient with a stage IV sacral pressure ulcer are most appropriate to assign or delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Assess and document wound appearance. b. Teach the patient pressure ulcer risk factors. c. Choose the type of dressing to apply to the ulcer. d. Measure the size (width, length, depth) of the ulcer. e. Assist the patient to change positions at frequent intervals.

d, e. Measuring the size of the wound and repositioning do not require judgment, patient teaching, or evaluation of care. The other interventions listed relate to assessment, judgment, and teaching, all of which are responsibilities of the RN. However, the LPN can reinforce teaching by the RN. The unlicensed assistive personnel may also be able to help with repositioning, if delegated by the RN.

A 66-yr-old African American patient is scheduled to have a basal cell carcinoma on his cheek excised in his HCP's office. What discharge teaching is most important for the nurse to include for this patient? a. You will probably need radiation as well after the excision. b. It is good you are having it removed to avoid massive tissue destruction. c. It is too bad you can't have this done by laser because it leaves less scarring. d. Using the prescribed ointment and an adhesive bandage will promote the healing with less scarring.

d. Using the prescribed ointment to keep the wound moist and the bandage for protection will promote healing and less scarring. Radiation is not used after excision of BCC. Without treatment, BCC causes massive tissue destruction, but he has it treated. Laser surgery is not used for BCC, so this is not appropriate. The potential of keloid scarring may be included for this African American patient.

Oxygen Administration: All members of the health care team should be alert to

possible problems with gas exchange in patients who are receiving oxygenation.

Patients who are hypoxemic should be cared for by

the registered nurse (RN) until they consistently have O2 saturations ≥90%.

Skin Care: Role of Licensed Practical Nurse

• Administer prescribed therapies such as dressings and oral or topical medications. • Monitor the skin for changes in appearance or texture that may indicate worsening of integumentary problem or adverse reactions to treatment. • Reinforce teaching done by the RN.

Wound care; Role of Dietitian

• Assess and monitor patient's nutritional status. • Establish an intervention together with the interprofessional team. • Monitor patient's progress toward achieving the goals of care.

Role of Nursing Personnel Registered Nurse (RN)

• Assess need for adjustments in O2 flow rate. • Evaluate response to O2 therapy. • Monitor patient for signs of adverse effects of O2 therapy. • In many cases, choose the optimal O2 delivery device (e.g., a nasal cannula or simple face mask). • Teach patient and caregivers about home O2 use.

Skin Care Role of Nursing Personnel Skin Care: Role of Registered Nurse (RN)

• Assess patient's skin for acute and chronic integumentary problems. • Assess patient's risk factors for integumentary problems. • Document skin condition and risk factor assessment, and develop a plan of care. • Determine whether patient is taking drugs that increase photosensitivity. • Teach about risks associated with sun exposure and methods for decreasing exposure to the sun. • Teach about therapies used for integumentary disorders, including dressings, baths, and oral or topical medications used on an outpatient basis. • Evaluate treatment for effectiveness and any adverse effects.

Wound Care; Role of Registered Nurse (RN)

• Assess patients for pressure ulcer risk and develop a plan of care to prevent the development of pressure ulcers. • Assess patients for factors that may delay wound healing and develop a plan of care to address these factors. • Assess and document initial wound appearance, including wound size, depth, color, and drainage. • Plan nursing actions to assist with wound healing, including wound care, positioning, and nutritional interventions. • Choose dressings and therapies for wound treatment (in conjunction with the HCP and or wound care specialist). • Implement wound care for complex or new wounds, including negative-pressure wound therapy and hyperbaric O2 therapy. • Evaluate whether wound care is effective in promoting wound healing. • Provide teaching to patient and caregivers about home wound care and pressure ulcer prevention.

Role of Other Team Members Respiratory Therapist

• Assist in optimal O2 delivery device (e.g., nasal cannula or simple face mask). • Make sure equipment is clean and replaced as needed. • Check accuracy of O2 delivery and assess need for adjustments in O2 flow rate. • Evaluate response to O2 therapy.

Skin Care: Role of (UAP)

• Assist patient with bathing. • Apply wet dressings to skin or add medications (such as oilated oatmeal) to patient baths (consider state nurse practice act and agency policy). • Report changes in skin appearance or patient complaints of discomfort to the RN.

Urinary Catheter Care; Role of Registered Nurse (RN)

• Determine need for catheterization, but HCP must order. • Choose appropriate type and size of catheter. • Insert catheter in patient with urethral trauma, pain, or obstruction. • Develop plan of care to decrease risk for infection in patient with indwelling catheter.

Suctioning & Trach care: Role of Respiratory Therapist

• Ensures proper equipment is available for suctioning and tracheotomy care • Has similar role to that of RN (see above)

Licensed Practical Nurse (LPN)

• For stable patients, adjust O2 flow rate depending on desired O2 saturation level.

Urinary Catheter Care; Role of Licensed Practical-Vocational Nurse (LPN)

• Insert intermittent or indwelling catheter for uncomplicated patients. • Irrigate the catheter if obstruction is suspected in stable patients (e.g., in long-term care).

Wound care; Role of UAP

• Perform dressing changes for chronic wounds using clean technique (must consider state nurse practice act and agency policy). • Empty wound drainage containers and document drainage on intake and output record. • Report changes in wound appearance or drainage to RN.

Wound care; Role of Licensed Practical Nurse (LPN)

• Perform sterile dressing changes on acute and chronic wounds. • Apply ordered topical antimicrobials and antibactericidals to wounds. • Apply prescribed dressings or medications for wound debridement. • Collect and record data about wound appearance. • Reinforce teaching that was provided by the RN.

Suctioning & Trach care: Role of UAP

• Provide oral care to patient with a tracheostomy. • Suction patient's oropharynx (after being trained and evaluated in this procedure). • Report increased need for oropharyngeal suctioning to the RN.

Urinary Catheter Care; Role of Unlicensed Assistive Personnel (UAP)

• Provide perineal care around the catheter with soap and water. • Anchor the catheter in place (upper thigh in women and lower abdomen in men). • Notify RN about changes in skin condition, especially around meatus

Unlicensed Assistive Personnel (UAP)

• Use pulse oximetry to measure O2 saturation. • Report O2 saturation level to RN. • Assist patient with adjustment of O2 delivery devices (e.g., nasal cannula, face mask). • Report to RN any change in patient level of consciousness or complaints of shortness of breath.