Nursing Process and Delegation

Delegation process

1. Assess and Plan 2. Communication 3. Surveillance and Supervision 4. Evaluation and Feedback

5 rights of delegation

1. Right task 2. Right circumstance 3. Right person 4. Right direction/communication 5. Right supervision/evaluation

A graduate nurse is caring for clients and does not want to delegate tasks to the LPN/LVN because the nurse feels that the responsibility for care belongs to the RN. As a result, the new nurse may: 1.Experience increased client satisfaction. 2.Lose the trust of coworkers. 3.Gain confidence that tasks will be done. 4.Feel pride when clients are cared for appropriately.

2

The new nurse is interviewing for a position on a medical/surgical unit. The nurse asks the manager what opportunities the nurse will have to develop skills, especially delegation. The manager tells the nurse that promoting delegation is a goal for the unit because: 1.RNs are too valuable to do bed baths. 2.Client satisfaction increases. 3.There is not enough qualified staff. 4.Productivity is too high.

2

An unlicensed assistive person (UAP) has previously performed client transfers (bed to chair) safely on many occasions. It would be inappropriate to delegate this unsupervised task to the UAP under which of the following conditions? 1.The unit has a new wheelchair. 2.The client is older. 3.It is the client's first time out of bed after surgery. 4.The UAP has just returned from an extended leave of absence.

3

An RN has been assigned to care for several clients on the shift. An admission experiencing pneumonia is to arrive from the emergency department. The nurse plans to delegate which of the following to the LPN/LVN regarding this client? 1.Administering IV push morphine for pain 2.Performing admission assessment 3.Taking the telephone orders for morphine from the physician 4.Performing a focused assessment

4

A client asks the student nurse to explain the pathophysiology of diabetes. The student nurse does not know the answer to this question. What should the student respond to the client? A) "I do not know, but I will find out." B) "You'll have to ask the doctor that question." C) "Why do you need to know that?" D) "I do not know."

A

A client is complaining of pain in the lower-left quadrant of his abdomen. The nurse prepares to auscultate the lower abdomen and notes that the client has a great deal of hair there. Which action by the nurse is appropriate prior to auscultating the client's abdomen? A) Moistening the abdominal hair B) Documenting that the client has hirsutism C) Cutting the client's hair over the entire abdomen D) Discontinuing the use of auscultation and palpating the abdomen only

A

A goal of care for a client with congestive heart failure (CHF) is for serum sodium levels to be within normal limits. Which information documented in the medical record would indicate that the client is not meeting this goal? A) The client is experiencing dependent edema. B) The client experiences joint pain. C) The client is constipated. D) The client is experiencing wheezing respirations.

A

A nursing student is reporting the care given to a patient. He/she states, "The patient said his leg pain was back so I checked his medical record & he received pain medication 6 hours ago. The order reads q 4 hrs. prn for pain so I decided he needed it. I administered the medication & checked with him 40 minutes later. He stated that his pain is going away". Which step of the nursing process did the student leave out? A. Assessment B. Planning C. Intervention D. Evaluation

A

A postoperative client is transferred to the medical-surgical unit from the intensive care unit (ICU). The client asks the assigned nurse why unlicensed assistive personnel (UAP) help with range-of-motion exercises. Which is the best response by the nurse? A) "Your condition has improved, so I delegated that part of your care to the UAP." B) "You do not need me to ambulate you." C) "The charge nurse made the decision to have the UAP assist you when walking." D) "I assigned all of your care to the UAP."

A

An older adult client is experiencing confusion, a temperature of 101.5°F, bruising to the arms and legs, and decreased urine output. The medical diagnosis is a urinary tract infection. Which is the most appropriate nursing diagnosis for this client? A) Risk for Injury B) Ineffective Breathing Pattern C) Activity Intolerance D) Impaired Memory

A

By the 2nd post-op day, a patient has not achieved satisfactory pain relief. Based on this evaluation, what should the nurse do next according to the nursing process? A. Reassess the patient to determine the reasons for the unsatisfactory pain relief B. See whether the pain lessens during the next 24 hours. C. Change the plan to ensure the patient achieves adequate pain relief D. Teach the patient about the plan of care for managing his pain.

A

During a health history, a client becomes upset because the nurse is asking many questions. Which response by the nurse is the most appropriate in this situation? A) "I use the answers to determine your current health needs." B) "I am sorry the questions disturb you." C) "I will skip the questions that bother you." D) "I cannot help you if you do not answer me."

A

During evaluation, the nurse must gather information about the patient to :A. Identify whether the patient outcomes have been met. B. Organize resources to proceed with implementing interventions. C. Establish patient-centered outcomes that are measurable & realistic D. Determine the priority of care & appropriate interventions.

A

How does accountability differ from responsibility? A) Responsibility involves specific tasks that must be completed in order to fulfill a role, whereas accountability involves being answerable for the outcomes of those tasks. B) Accountability involves specific tasks that must be completed in order to fulfill a role, whereas responsibility involves being answerable for the outcomes of those tasks. C) Responsibility involves the professional standards used to determine what a nurse should or should not do, whereas accountability involves taking ownership of the actions of others. D) Accountability involves the professional standards used to determine what a nurse should or should not do, whereas responsibility involves taking ownership of the actions of others.

A

The home health nurse is visiting a client who is 2 weeks postoperative from a coronary artery bypass surgery. The client has lost 10 pounds, is continuing to experience pain, and is not eating. What should be the nurse's next action? A) Examine the current interventions for pain relief. B) Refer the client to social services. C) Contact Meals on Wheels so that the client will eat. D) Revise the goals in the current plan of care.

A

The nurse completes a teaching session on wound care for a client who will require dressing changes after discharge. The nurse then evaluates the effectiveness of the teaching session and determines that more education is required. Which statement by the nurse is appropriate in this situation? A) "Let me clarify again some of the steps that are required during wound care." B) "You didn't pay attention, did you?" C) "Here, let me do it for you." D) "I don't think you understood me correctly the first time."

A

The nurse delegated to an unlicensed assistive personnel (UAP) the task of assisting a client with a simple dressing change. The client was formerly able to do the procedure, but because of painful arthritis is now unable to perform the redressing. The UAP has done this procedure before. Which must the nurse emphasize to the UAP? A) Report to the nurse immediately anything unusual, such as bleeding or infection. B) The nurse should demonstrate the steps of the procedure. C) Make the client do most of the procedure and report the expected output. D) The UAP should do health teaching while performing the procedure.

A

The nurse is assessing an older adult client who is confused. The client is accompanied by his adult son. Who can the nurse employ as a primary source of data when assessing this client? A) The client himself B) The client's adult son C) A nurse who cares for the client at the retirement home D) The client's primary healthcare provider

A

The nurse is caring for a client who received analgesic medication via central line to treat pain associated with cancer. After reassessing the client's response, which section of the PIE record will the nurse use when documenting the client's care? A) Evaluation B) Progress notes C) Problem D) Intervention

A

The nurse is preparing to conduct a physical examination of a client's head and neck area. The client is paralyzed from the neck down. Which action by the nurse is appropriate when conducting the physical assessment of this area? A) Supporting the client during the examination B) Placing the client in an armless regular chair C) Placing the client in Sims position D) Placing the client in supine position

A

The nurse is providing care for a client who is newly diagnosed with chronic obstructive pulmonary disease (COPD). In this scenario, which action by the nurse would be considered an example of therapeutic communication? A) The nurse asks appropriate questions about the client's medical history. B) The nurse closes the conversation with an anecdote about breathing. C) The nurse plans to tell the client about a COPD support group. D) The nurse bonds with the client by describing her own experiences living with COPD.

A

The nurse is providing care to a client who is diagnosed with hypertension. Which response by the nurse is an appropriate example of informational confrontation with the client? A) "I noticed you rubbing your head and your eyes. Are you hurting? Let's take your blood pressure." B) "I heard raised voices when I was coming down the hall to your room. Are you upset?" C) "It is 3 p.m. and time to take your blood pressure before I give you your medication." D) "Is the blood pressure medication making your head hurt?"

A

The nurse is working on a medical-surgical unit that is short staffed due to a callout. The manager of the unit was unable to replace the nurse, so the extra clients were assigned to the remaining nurses. The manager was able to get the help of unlicensed assistive personnel (UAP) from the house pool to help on the unit. Which action by the nurses would ensure effective care for the client? A) Delegate vital signs and weights to the UAP. B) Explain to the manager that care may be compromised if another nurse does not work the shift. C) Tell the clients their care will be sparse. D) Assign care of invasive lines to the UAP.

A

The urgent care clinic nurse is treating a client who is experiencing abdominal pain. The client states, "I think I ate tainted food last night." What should the nurse do after the client states that the food was tainted? A) Ask the client open-ended questions to further assess the situation. B) Tell the client the healthcare provider does not need to assess the client. C) Call an ambulance before assessing the client any further. D) Advise the client to take an antacid.

A

The nurse is providing care to a client who is newly diagnosed with human immunodeficiency virus (HIV). Which statements by the nurse could inhibit the development of therapeutic communication with this client? Select all that apply. A) "I am so happy today! I just found out that I got accepted into nurse practitioner school!" B) "Well, I guess your lifestyle finally caught up to you." C) "One of my cousins has AIDS. It is hard to watch him die." D) "Tell me your feelings about the diagnosis." E) "Would you like to talk about the new medications you've been prescribed?"

A,B,C

When the nurse receives a telephone order from the healthcare provider's office, which guidelines should the nurse use to ensure the order is correct? Select all that apply. A) Ask the provider to repeat or spell out medication. B) Read the order back to the provider. C) Ask the provider to speak slowly. D) Know agency policy for telephone orders. E) Sign the provider's name and credentials.

A,B,C,D

A nurse-supervisor is encouraging nurses to delegate responsibilities whenever possible. Which criteria are used to determine tasks that can be delegated? Select all that apply. A) Does the delegate have the appropriate skills to perform the task safely? B) How busy are you? C) Is the client frequently complaining? D) Does the task require client education? E) Is the task unpleasant?

A,D

A nurse enters a client's room to evaluate the response to IV pain medication administered by request 20 minutes earlier. The nurse finds the client in the same position as when the medication was administered. The client states, "I do not want to move." The nurse asks the client to rate the current level of pain. Which aspects of the nursing process do these action represent? Select all that apply. A) Assessment B) Diagnosis C) Planning D) Implementation E) Evaluation

A,D,E

A nursing instructor is reviewing the steps of the nursing process with students. The students identified which of the following as objective data? Select all that apply... A. Resp. rate of 22/min B. "I can walk only 3 steps before my legs hurt C. Pain level 3 on a 0-10 scale D. Skin pink, warm, dry E. Urine output 300mls/8 hours F. Dressing clean, dry, intact

A,D,E,F

A construction worker admitted to the unit with a chest injury and broken ribs from a fall from a ladder has nursing diagnoses of "Disturbed Sleep Pattern," "Ineffective Breathing Pattern," and "Risk for Infection." The client states, "I've never been sick a day in my life and am really worried about how I can support my family while I'm out of work." When evaluating the client's plan of care during the shift, the nurse adds the nursing diagnosis "Anxiety" to the plan of care. Which diagnosis would be the priority for nursing interventions? A) Risk for Infection B) Ineffective Breathing Pattern C) Disturbed Sleep Pattern D) Anxiety

B

A nurse educator is teaching a group of students about therapeutic touch. In which situation is it appropriate to use therapeutic touch as a means of communication? A) When a client's family member is making inappropriate comments to the nurse B) When an upset spouse is alone and the client has just expired C) When speaking to a client with a history of physical abuse D) When a young male client asks a young student nurse for a hug

B

A nurse is caring for a client with cancer who is struggling with chronic pain. The nurse tells the client, "It is normal to feel frustrated about the discomfort." Which skill associated with the working phase of the nurse-client relationship does the nurse's statement best reflect? A) Confronting B) Respect C) Concreteness D) Genuineness

B

An experienced delegator is mentoring a newly appointed nurse in the hospital. The new nurse states, "I am hesitant to delegate tasks to unlicensed assistive personnel (UAP) because I am afraid they will not be done correctly." Which response by the experienced delegator is appropriate? A) Tell her not to delegate any tasks unless she is completely confident. B) Tell her to clearly identify the task and expectations and then to monitor the delegate's progress. C) Tell her that delegation often results in a decrease in job satisfaction. D) Tell her that her job responsibility requires that she do everything herself.

B

The nurse in the clinic is assessing an adult client who has signs and symptoms of heart failure. Which of the following lifestyle habits would be useful for the nurse to assess before developing the client teaching plan? A) The client's occupation B) The client's diet C) The client's usual sleep schedule D) The client's marital status

B

The nurse is assessing an older adult client during a routine health maintenance visit. To assess the client's range of motion of the knees, which action by the nurse is appropriate? A) Seat the client and extend each knee until the client alerts the nurse of severe pain. B) Seat the client and extend each knee until the client alerts the nurse of any pain whatsoever. C) Place the client prone and gently lift the entire right leg, followed by the entire left leg. D) Have the client stand and extend each knee as far as it will go.

B

The nurse is conducting a health history as part of a nursing assessment. The client says to the nurse, "I am allergic to penicillin." Which assessment question would best help the nurse learn more about the client's allergy? A) "Where did you experience the reaction?" B) "What type of reaction occurred?" C) "How long did your symptoms last?" D) "Do any other family members have this same allergy?"

B

The nurse is conducting a health history on a client who is being admitted to a medical-surgical unit for the treatment of chronic pain. The client is concerned about privacy and asks why it is necessary for the nurse to ask for private information and then document it in the medical record. Which response by the nurse is most appropriate? A) "You will be able to read the record and review your care." B) "Documentation decreases the likelihood that you will have to repeat this information to others who will care for you." C) "Your family can review the record and ensure that your care is appropriate." D) "A record ensures there are no breaches of confidentiality."

B

The nurse is preparing to assess a client who is experiencing difficulty breathing. Before palpating the client's abdomen, which nursing action is appropriate? A) Administering 10 L of oxygen to the client B) Having the client remain upright C) Placing the client in a modified Sims position D) Asking the client to bend over a table

B

Which statements accurately reflect the distinction between nursing diagnoses and medical diagnoses? Select all that apply. A) A nursing diagnosis is determined following an assessment and analysis of data gathered only by registered nurses; a medical diagnosis is determined following an assessment and analysis of data gathered only by physicians. B) A nursing diagnosis changes as the client's responses to an illness or health situation change; a medical diagnosis remains the same as long as the disease process persists. C) A nursing diagnosis describes a client's physical, sociocultural, psychological, and spiritual responses to an illness or health condition; a medical diagnosis refers to disease processes. D) A nursing diagnosis considers the etiology of the health problem to give direction to required nursing care; a medical diagnosis does not consider the etiology of the health problem to give direction to medical care. E) A nursing diagnosis requires the nurses to consider standards and norms as well as cues from clients in discerning an appropriate nursing diagnostic label; a medical diagnosis uses standards and norms only.

B,C

A client who has just been diagnosed with type 2 diabetes mellitus is being instructed by the nurse regarding diet and exercise. Which client statements indicate that further teaching is required? Select all that apply. A) "I should talk to the doctor about an exercise program." B) "I don't need to watch my diet as long as I take my insulin." C) "I need to limit the amount of fat in my diet." D) "I should eat a candy bar when my energy is low." E) "I will test my blood sugar before meals and at bedtime."

B,D

A nurse educator is providing information to a group of nursing students regarding appropriate assessment techniques that can be applied across the life span. Which statements should the educator include in the teaching session? Select all that apply. A) "Auscultate the chest while the client is sleeping to obtain the most accurate assessment of the heart." B) "Use standard precautions during the history and physical examination process." C) "Perform invasive procedures like pharyngeal and otic exams at the end of the assessment." D) "Use age-appropriate terminology for explaining procedures and actions." E) "Use the assessment process to teach about exam procedures and findings."

B,D,E

A novice nurse is working with a client who is admitted to a medical-surgical unit. The nurse is establishing a therapeutic relationship with the client by conveying empathy. Which statement by the nurse best exemplifies empathy? A) "I wouldn't be afraid if I were you." B) "You shouldn't have done it that way." C) "You seem to be frightened by the procedure. Tell me how you are feeling." D) "I know just how you feel, because my mother has the same illness."

C

A staff nurse at a hospital calls a long-term care facility that has just received transfer of care for a client. The hospital nurse reports the physician's medication orders to a nurse at the receiving facility. The hospital nurse does not have prescribing privileges. What is the responsibility of the nurse at the receiving facility in order to reduce the fear of liability? A) Withhold medications until the facility's physician can assess the new client B) Administer medications to the client immediately C) Verify the order with the prescribing physician D) Submit the medication order to the on-site pharmacy as soon as possible

C

An adult client and her spouse are seen in an urgent care clinic. The client presents with a temperature of 102°F, complains of nausea, and has experienced vomiting and diarrhea for 12 hours. The nurse notes that the client's mucous membranes are pale and dry and suspects that the client is dehydrated. Which action by the nurse is the most appropriate? A) Ask the spouse for more information. B) Assess for pedal edema. C) Assess skin turgor. D) Repeat the temperature measurement.

C

The healthcare provider prescribes digoxin for a client who will be discharged in the morning. When documenting the order in the medical record, which action by the nurse is most appropriate? A) Entering "digoxin, .0125 mg QD" B) Entering "digoxin, 0.0125 mg QD PO" C) Entering "digoxin, 0.0125 mg, once daily by mouth" D) Entering "digoxin, 1 pill each day"

C

The nurse is caring for an older adult client in a long-term care facility. Which behavior by the nurse conveys physical attending when communicating with this client? A) Facilitating and taking action when needed B) Maintaining a proper social distance when speaking with the client C) Leaning toward the client during conversation D) Being concrete about actions that need to be taken during client care

C

The nurse is caring for an older adult client with decreased energy who needs to get up to prevent the development of pressure ulcers. The client is unable to ambulate and wants to be alone. What should the nurse do? A) Notify the healthcare provider of the client's noncompliance. B) Leave the client alone until ready to get out of bed. C) Gain knowledge about the client from family to gain compliance. D) Proceed to get help to get the client out of bed.

C

The nurse is caring for an older school-age client who is sleeping when the menu choices for dinner are brought to the room. Which intervention should the nurse use to meet the dietary needs of this client? A) Wake the child to choose a meal for dinner. B) Order chicken nuggets because most children like this meal. C) Ask the dietary worker to come back later. D) Ask the parents to bring dinner from home for the client.

C

The nurse is caring for several medical-surgical clients. The nurse has delegated skin care of an incontinent client to new unlicensed assistive personnel (UAP) on the unit. Which action by the nurse will improve effectiveness of the client care provided? A) Ask the client if the care was appropriate. B) Ask the UAP if the care was given. C) Demonstrate the appropriate care needed and have the UAP give a return demonstration. D) Closely observe the UAP each time the care is given.

C

The nurse is working on a unit with unlicensed assistive personnel (UAP). One nurse refuses to use the UAP and is consistently leaving nursing tasks for the next shift that have yet to be completed. Which is the most likely reason the nurse is not using the UAP to assist with client care? A) Avoidance of responsibility B) Overdependence on others C) The belief that no one else can perform a task as well as the nurse can D) The state nurse practice act

C

Use of flow sheets would be most appropriate during which phase of the nursing process? A) Evaluation B) Diagnosis C) Implementation D) Planning

C

What is the first phase in the therapeutic nurse-client relationship? A) Introductory phase B) Working phase C) Preinteraction phase D) Anticipatory phase

C

A nursing instructor is reviewing which actions a nurse can initiate without a medical provider's prescription, with a group of nursing students. The students should identify which of the following as nurse-initiated? Select all that apply... a.Give MSO4 1-2 mg IV q 1 hr. prn pain b.Insert an NG tube to relieve a patient's gastric distention c.Show a patient how to use progressive muscle relaxation d.Perform a daily bath after the patient's evening meal e.Reposition a patient q 2 hrs. to prevent pressure ulcers

C,D,E

A client recovering from knee surgery is being prepared to ambulate for the first time. Prior to getting the client up, what should the nurse do? A) Ask the client about readiness to walk. B) Call for a wheelchair to start the process. C) Conduct a breathing assessment. D) Evaluate the client's level of pain.

D

A nurse receives a shift report and is preparing to care for clients assigned on a medical-surgical unit. Which client should the nurse plan to assess first? A) The client who needs assistance with activities of daily living B) The client who needs help ambulating to the bathroom C) The client with a pain rating of 3/10 D) The client experiencing shortness of breath

D

An older adult client with heart failure is experiencing activity intolerance due to dyspnea on exertion. Which nursing intervention is a priority for the client? A) Complete all nursing care at the end of the shift. B) Delegate care for the client to an aide. C) Complete all nursing care in the morning. D) Pace nursing care throughout the shift.

D

Data that are detectable by an observer or can be measured or tested against an accepted standard are known as A) subjective data or symptoms. B) objective data or symptoms. C) subjective data or signs. D) objective data or signs.

D

Handoff communication, or the transfer of data during transitions in care, includes an opportunity to ask questions, clarify, and confirm the information being passed between sender and receiver. What is the main objective for ensuring effective communication during a client handoff? A) To avoid lawsuits B) To make sure all documentation is complete C) To facilitate quality improvement D) To ensure client safety

D

The nurse delegates vital signs and daily weights of assigned clients to the unlicensed assistive personnel (UAP) on duty. Which is the reason for the nurse to assess each client throughout the shift? A) The UAP cannot report to the next shift. B) The UAP is not trustworthy. C) The nurse maintains the authority to care for the clients. D) The nurse remains accountable for the clients' care.

D

The nurse is caring for a school-age client who is scheduled to have major heart surgery the next morning. The nurse enters the room to administer a medication and finds the client crying. Which response by the nurse is most therapeutic? A) "Would you like some toys from the playroom?" B) "I'm going to go get the doctor." C) "You shouldn't cry. You are not in pain." D) "It is okay to cry. I know this is scary."

D

The nurse is collecting data about a client's current health status. Which statement would assist in gathering subjective data about the client? A) "Your eyelid is red and swollen." B) "Your skin appears to be dry and irritated." C) "I see that you have bruises on your legs." D) "Tell me why you have difficulty sleeping."

D

The nurse is conducting a class for a group of expectant mothers regarding basic infant care techniques. What goal will allow the nurse to best evaluate the mothers' learning? A) The mothers will be able to set goals for the next class session. B) The mothers will be able to pass a written test on how to bathe a newborn infant. C) The mothers will be able to review the major points of the class. D) The mothers will be able to provide a return demonstration of a bath on a newborn doll.

D

Which of the following statements by the nurse is an example of the therapeutic communication technique of offering self? A) "Would you like to talk with me about your emotions right now?" B) "I'm not sure I understand. Please tell me more about the situation." C) "I don't know the answer to your question, but I will check with the physician." D) "I'll stay here with you until your family arrives."

D

The nurse is conducting a physical assessment of a middle-aged female client during an annual exam. What should the nurse assess that is particularly relevant to this age group? Select all that apply. A) Speech and language B) Body development and growth C) Sleeping patterns D) Ability to carry out activities of daily living (ADLs) E) Body mass index (BMI) measurement

D,E