EXAM ELABORATIONS (A+) PRIORITIZATION AND DELEGATION IN NURSING

PRIORIZATION AND DELEGATION FOR NURSING Question 1 See full question Several hours into a shift, a nurse on a very busy medical-surgical unit privately asks the charge nurse to change her assignment. She is frustrated because she has had to devote so much time and energy to helping a newly licensed nurse provide discharge teaching for clients with diabetes mellitus. The charge nurse should: Correct response: • offer to assist with the discharge teaching needs. Explanation: Staff members need to know the charge nurse is a supportive leader who respects their honesty and stands behind them. By offering to help with discharge teaching, the charge nurse is actively engaging with her staff at a time of need. Changing all the assignments on this extremely busy floor would be counterproductive. Insisting that the staff member follow through with her assignment disrespects her request and genuine need. Providing a float nurse could help, but there are no guarantees a float nurse is available. Remediation: • Discharge Question 2 See full question During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis Correct response: • Providing a solution of viscous lidocaine for use as a mouth rinse Explanation: To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen viscous lidocaine for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.) The nurse also may administer systemic analgesics as ordered. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or practical. Instead, the nurse should stay alert for this potential problem to ensure prompt treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and infection but wouldn't decrease pain in this highly susceptible client. Checking for signs and symptoms of stomatitis also wouldn't decrease the pain. Remediation: • Impaired Oral Membrane Question 3 See full question A nurse has been caring for an adolescent client in a residential facility. The child has been through a series of foster placements since infancy with no success in any placement until the age of 7 when placed with a middle-aged single woman. The client thrived there until the woman was killed in a car accident. The client attempted suicide after her foster mother died in response to the loss and the child was placed in the residential facility. The nurse has become close to this client and wants to help her address her issues and move on with her life. Which comment to the manager demonstrates that the nurse understands the client’s issues and is able to respond appropriately to the client’s needs? You Selected: • "It is difficult for her to love and trust again after her losses. In this facility, she can learn to deal with her loss in a less emotionally charged environment than a foster home." Explanation: The severe emotional trauma the girl has experienced will likely make it difficult for her to be successful in an adoptive placement at the present time, whether that placement is with someone she knows (the nurse) or another adoptive family. Additionally, adoption by the nurse is inappropriate because it blurs the lines between her professional and personal life and is likely to confuse the client. It is clear that the client has many issues and that love alone is not likely to solve all her problems. Treatment at the residential facility will allow her to work through emotional issues in a more therapeutic environment. Though not currently ready for adoption, she may be ready for adoption in the future after sufficient treatment. Question 4 See full question A client is about to undergo cardiac catheterization for which he signed an informed consent. As the nurse enters the room to administer sedation for the procedure, the client states, "I'm really worried about having this open heart surgery." Based on this statement, how should the nurse proceed? Correct response: • Withhold the medication and notify the physician immediately. Explanation: The nurse should withhold the medication and notify the physician that the client does not understand the procedure. The physician then has the obligation to explain the procedure better to the client and determine whether or not the client understands. If the client does not understand, he cannot give a true informed consent. If the medication is administered before the physician explains the procedure, the sedation may interfere with the client's ability to clearly understand the procedure. The nurse may not just medicate the client and document the finding; the physician must be notified. The procedure does not need to be cancelled, only postponed until the client receives more education and is able to give informed consent. Remediation: • Decisional Conflict Question 5 See full question Which action associated with restraint use on a confused client can be delegated to an unlicensed healthcare worker/nursing assistant? • Completion of range of motion on limbs restrained Question 1 See full question Four clients have been admitted to the cardiac intensive care unit after experiencing acute myocardial infarctions. Each client has sustained a percentage of cardiac damage. Which client is most in need of interventions to prevent the development of cardiogenic shock? Correct response: • The client with 40% damage Explanation: At least 40% of the heart muscle must be involved for cardiogenic shock to develop. In most circumstances, the heart can compensate for up to 25% damage. An infarction involving 70% of the heart would have likely already caused cardiogenic shock. Question 2 See full question The nurse is providing postoperative care to a client with sickle cell anemia. What is the most important intervention for the nurse to include in the plan of care? Correct response: • Increasing fluids Explanation: The main surgical risk of anesthesia is hypoxia. Emotional stress, demands of wound healing, and the potential for infection can each increase the sickling phenomenon. Increased fluids are encouraged because hydration promotes hemodilution, and decreases sickling. Preparing the child psychologically to decrease fear will minimize undue emotional stress, but is not a priority. Deep coughing is encouraged to promote pulmonary hygiene and prevent respiratory tract infection. Analgesics are used to control wound pain and to prevent abdominal splinting and decreased ventilation. Remediation: A hospitalized client, with a productive cough, chills, and night sweats is suspected of having active tuberculosis (TB). What is the nurse’s most important intervention? You Selected: • Maintain the client on respiratory isolation Correct response: • Maintain the client on respiratory isolation Explanation: This client is showing signs and symptoms of active TB and, because of the productive cough, is highly contagious. He should be admitted to the hospital and placed in respiratory isolation. Three sputum cultures should be obtained to confirm the diagnosis. Question 4 See full question The nurse is caring for a client with type 1 diabetes mellitus. At 3:00 AM, the nurse finds the client disoriented to time and place, diaphoretic, and complaining of palpitations. What is the nurse’s priority intervention? You Selected: • Check blood glucose level Correct response: • Check blood glucose level Explanation: Check the blood glucose level first when symptoms arise, then proceed with treatment according to the results. If the client is hypoglycemic, administration of a simple carbohydrate is appropriate. If the client is conscious, the carbohydrate may be given orally. If consciousness is altered, subcutaneous or intramuscular glucagon is appropriate. This client is showing symptoms of hypoglycemia, additional insulin would further lower the blood glucose. Remediation: • Diabetes Mellitus (Type 1), Long-Term Care Question 5 See full question A two-month-old infant arrives with a heart rate of 180 bpm and a temperature of 103.1° F (39.5° C) rectally. What is the most appropriate initial nursing intervention? You Selected: • Give acetaminophen Correct response: • Give acetaminophen Explanation: Acetaminophen should be given to decrease the temperature. A heart rate of 180/bpm is normal in an infant with a fever. A tepid sponge bath may be given to help decrease the temperature and calm the infant. Carotid massage, and placing the infant’s hands in cold water are attempts to decrease the heart rate through vagal maneuvers. This will not work because the source of the increased heart rate is fever. Fluid intake is encouraged after the acetaminophen is given to help replace insensible fluid losses. Remediation: • Acetaminophen Question 6 See full question A 19-month-old child with croup is crying as a nurse tries to auscultate breath sounds. What is the nurse’s most appropriate intervention? You Selected: • Hand the stethoscope to the child to examine before auscultating his lungs Correct response: • Hand the stethoscope to the child to examine before auscultating his lungs Explanation: Children at this age are very curious. Encouraging the child to play with the stethoscope will distract him and help gain trust so that the nurse will be able to auscultate the lungs. Ignoring the child’s crying may only upset him more, and will not help the nurse gain his trust. The nurse should ask the parents to help quiet and comfort the child. Asking the parents to leave may only upset the child more. The nurse should speak to the child in a soft, comforting tone of voice. Question 7 See full question A client in early labor tells the nurse that she has a thick, yellow discharge from both of her breasts. What is the nurse’s most appropriate intervention? You Selected: • Inform the client that the discharge is colostrum, and a normal finding Explanation: After the fourth month, colostrum may be expressed. The breasts normally produce colostrum for the first few days after birth. Milk production begins one to three days postpartum. A clinical breast examination isn’t usually indicated in the intrapartum setting. Although a culture may be indicated, it requires advanced assessment as well as a medical order. Remediation: • Breast Care For Non-Nursing Mothers Question 8 See full question Which nursing intervention is priority for an infant during the first 24 hours following surgery for cleft lip repair? Correct response: • Carefully clean the suture line after feedings to reduce the risk of infection Explanation: The suture line must be carefully cleaned with a sterile solution after each feeding to reduce the risk of infection, which could adversely affect the healing and cosmetic results. The infant shouldn’t be placed in the prone position, because this puts pressure on the incision and may affect healing. Anticipatory care should be provided to reduce the risk of the infant crying, which puts strain on the incision. Pacifiers and other firm objects should not be placed in the infant’s mouth because they can disrupt the suture line. Remediation: Question 9 See full question A nurse on a maternity unit witnesses a mother slapping the face of her crying neonate. What is the nurse’s priority action? Correct response: • Take the neonate to the nursery, inform the health care provider of what was witnessed, and notify social services Explanation: The neonate’s safety and protection are the nurse’s first priority. The nurse should immediately take the neonate to the nursery and inform the health care provider of the abuse. As an advocate for the neonate, the nurse provides the health care provider with an opportunity to examine the child for injuries. The nurse should not confront the client. Observing the mother for further incidents may be part of the revised care plan, however this incident requires immediate intervention. Question 10 See full question Two hours after starting total enteral nutrition (TEN) through a nasogastric tube, a client starts to have abdominal distention. Which action should the nurse take first? Correct response: • Stop the feeding Explanation: Clients receiving TEN are at risk for abdominal distention due to rapid feeding or delayed emptying of the stomach contents. The nurse should stop the feeding to prevent further distention and then continue to assess the cause of the distention. Aspirating the stomach contents and repositioning the tube may be necessary but are not the priority. A client receiving a nasogastric tube feeding should be placed in an upright or Fowler’s position to prevent the risk of aspiration. Question 1 See full question Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test? Correct response: • A client infected with the human papillomavirus (HPV) Explanation: