FOCUS ON DELEGATING, Etc - Questions, Answers and Rationales

Focus on Delegating, Etc.
1.ID: 0
A registered nurse (RN) on the 7 a.m.–3 p.m. shift is planning client assignments for the day. Which clients would be appropriate for the RN to assign to the licensed practical nurse (LPN)? Select all that apply. A. A client who had a mastectomy 2 days ago Correct B. A client with type 1 diabetes mellitus who has a foot ulcer Correct C. A client with left-side weakness who will need assistance with personal care Correct D. A newly admitted client with chronic obstructive pulmonary disease (COPD) E. A client being transferred in from the intensive care unit with a deep vein thrombosis and a heparin drip
Rationale: When a nurse delegates aspects of a client’s care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. The client with COPD who was admitted during the night will need close monitoring of the respiratory status. An LPN may not administer most high-risk intravenous medications, including heparin. The client who has had a mastectomy and the client with a foot ulcer will likely require dressing changes, an activity that is within the scope of practice of the LPN. The client with left-side weakness requiring personal care assistance could also be assigned to the LPN.
Test-Taking Strategy: Use the process of elimination, focusing on the subject, assignment to the LPN. Recalling that an LPN may not administer high-risk intravenous medications will assist you in eliminating this option. Eliminate the newly admitted client with COPD, noting that this client will require a higher level of monitoring. Review the principles of delegating tasks if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Safety
HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety
Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and trends (8th ed., pp. 305, 308). St. Louis: Elsevier
Awarded 3.0 points out of 3.0 possible points.
2.ID: 1
A home care nurse is assigned to visit a prenatal client with a diagnosis of hyperemesis gravidarum (HEG). During physical assessment of the client, the nurse should first: A. Weigh the client B. Assess the client’s intake and output Correct C. Encourage the client to verbalize her feelings about the diagnosis D. Review the results of the hemoglobin and hematocrit determinations
Rationale: HEG is persistent, uncontrolled vomiting that begins before the 20th week of pregnancy. It can have serious consequence, including loss of 5% of prepregnancy weight, dehydration, ketosis, acid-base imbalance, and electrolyte imbalances. Physical assessment begins with determining the client’s intake and output, because these data provide information regarding hydration and the nutritional status of the client. The client’s weight would be obtained and the baseline value compared with previous and subsequent values. Additionally, the nurse would instruct the client in how to accurately check and monitor her weight. Laboratory data may need to be evaluated; increased hemoglobin and hematocrit values may occur as a result of dehydration. Encouraging the client to verbalize her feelings about the diagnosis is a component of the plan of care but is not the first intervention during physical assessment.
Test-Taking Strategy: Note the strategic word “first.” Use Maslow’s Hierarchy of Needs theory to eliminate the option that indicates encouraging the client to verbalize her feelings, recalling that physiological needs are the priority. To select from the remaining options, recall the description of HEG; this will direct you to the correct option. Review the priority physical assessment techniques in this disorder if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Nutrition
HESI Concepts: Collaboration/Managing Care – Care Coordination, Nutrition
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 589-590). St. Louis: Elsevier.
Awarded 1.0 points out of 1.0 possible points.
3.ID: 5
A registered nurse (RN) on the night shift has a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP)on the team and is planning the client assignments for the night. Which client does the RN assign to the LPN? Select all that apply. A. A client who undergoing a 24-hour urine collection B. A client with a nasogastric tube who underwent bowel resection 2 days ago Correct C. A client with urinary frequency who needs assistance in getting to the bathroom D. A client scheduled for renal dialysis in the morning who needs assistance with hygiene E. A client who has been fitted with skeletal traction of the right leg after an open reduction measuresCorrect
Rationale: When a nurse delegates aspects of a client’s care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. An LPN may perform certain invasive procedures. A client with a nasogastric tube who underwent bowel resection 2 days ago and a client in skeletal traction to the right leg after open reduction may safely be assigned to the LPN, because the LPN is capable of performing the nasogastric tube care, dressing changes, and monitoring for postoperative complications that the clients will require. Interventions such as assisting clients with ambulation and hygiene measures and performing noninvasive procedures — the types of tasks identified in the other options — may be assigned to a nursing assistant.
Test-Taking Strategy: Use the process of elimination, focusing on the subject, assignment to an LPN. Eliminate the options that are comparable or alike in that they are noninvasive procedures. Also note that the remaining options involve routine care of the postoperative client and activities that are within the scope of practice for the LPN. Review the principles of delegation if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Safety
HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety
Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8thed., pp. 262, 281-283). St. Louis: Mosby.
Awarded 2.0 points out of 2.0 possible points.
4.ID: 3
A nurse is monitoring a client with preeclampsia who is receiving intravenous magnesium sulfate to prevent seizures. The nurse notes that the client’s respiratory rate is 10 breaths/min. On the basis of this finding, the nurse first: A. Takes the client’s vital signs health care provider B. Contacts the health care provider C. Discontinues the magnesium sulfate Correct D. Checks the most recent serum magnesium sulfate level
Rationale: A respiratory rate slower than 12 breaths/min is a sign of magnesium toxicity. Other signs include the absence of deep tendon reflexes, altered sensorium, hypotension, and a serum magnesium level above the therapeutic range of 5 to 8 mg/dL (2.05 to 3.29 mmol/L). In this situation, the nurse would first discontinue the magnesium sulfate. The nurse would then take the client’s vital signs and contact the health care provider health care providerThe most recent serum magnesium level may be checked; however, a current serum level would provide more useful data.
Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Recalling that a respiratory rate slower than 12 breaths/min is a sign of magnesium toxicity will direct you to the correct option. Review these signs and the appropriate nursing interventions if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 595). St. Louis: Elsevier.
Awarded 1.0 points out of 1.0 possible points.
5.ID: 8
A client who has just undergone abdominal surgery calls the nurse and states, “I feel as if I just split open.” The nurse checks the abdominal incision and finds wound evisceration. The nurse immediately: A. Documents the findings B. Notifies the operating room C. Takes the client’s vital signs D. Contacts the health care provider Correct
Rationale: Wound evisceration is the total separation of a surgical incision or wound with extrusion of the internal organs or viscera through the open wound. When evisceration occurs, the nurse immediately calls for help and has the health care provider notified. The nurse stays with the client and positions the client with the hips and knees bent. The nurse then covers the abdominal wound with a sterile dressing moistened with sterile saline solution. The nurse would then take the client’s vital signs and document the occurrence. Since this is a surgical emergency, the operating room would be notified but this would not be done until directed to do so by the surgeon.
Test-Taking Strategy: Use the process of elimination and your prioritizing skills. Note the strategic word “immediately.” Recalling that wound evisceration is a surgical emergency will direct you to the correct option. Review the nursing actions to be taken immediately in the event of wound evisceration occurs if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, Caregiving
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Cargiving
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 180). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points. ...............Continued...........