Prioritization, Delegation & Management of Care for the NCLEX-RN Exam 1st Edition; ISBN: .

Prioritization, Delegation & Management of Care for the NCLEX-RN Exam 1st Edition; ISBN: 0. Table of Contents 1 Introduction to Prioritization, Assignment, Delegation, and Management 1 NCSBN BLUEPRINT FOR QUESTIONS 1 GUIDELINES FOR MAKING A DECISION 2 TYPES OF QUESTIONS 4 PUTTING THE PIECES TOGETHER 5 2 Cardiovascular Management 7 QUESTIONS 7 CARDIAC CLINICAL SCENARIO 20 ANSWERS AND RATIONALES 22 CLINICAL SCENARIO ANSWERS AND RATIONALES 40 3 Peripheral Vascular Management 43 QUESTIONS 43 PERIPHERAL VASCULAR DISEASES CLINICAL SCENARIO 54 ANSWERS AND RATIONALES 56 CLINICAL SCENARIO ANSWERS AND RATIONALES 74 4 Respiratory Management 77 QUESTIONS 77 RESPIRATORY CLINICAL SCENARIO 88 ANSWERS AND RATIONALES 90 CLINICAL SCENARIO ANSWERS AND RATIONALES 107 5 Gastrointestinal Management 109 QUESTIONS 109 GASTROINTESTINAL CLINICAL SCENARIO 120 ANSWERS AND RATIONALES 122 CLINICAL SCENARIO ANSWERS AND RATIONALES 139 6 Renal and Genitourinary Management 141 QUESTIONS 141 RENAL AND GENITOURINARY CLINICAL SCENARIO 152 ANSWERS AND RATIONALES 154 CLINICAL SCENARIO ANSWERS AND RATIONALES 171 ix 3313_FM_i-xii 14/03/14 5:13 PM Page ix x TABLE OF CONTENTS 7 Neurological Management 173 QUESTIONS 173 NEUROLOGICAL CLINICAL SCENARIO 185 ANSWERS AND RATIONALES 187 CLINICAL SCENARIO ANSWERS AND RATIONALES 204 8 Endocrine Management 207 QUESTIONS 207 ENDOCRINE CLINICAL SCENARIO 220 ANSWERS AND RATIONALES 221 CLINICAL SCENARIO ANSWERS AND RATIONALES 238 9 Integumentary Management 239 QUESTIONS 239 INTEGUMENTARY CLINICAL SCENARIO 250 ANSWERS AND RATIONALES 252 CLINICAL SCENARIO ANSWERS AND RATIONALES 269 10 Hematological and Immunological Management 271 QUESTIONS 271 HEMATOLOGICAL AND IMMUNOLOGICAL CLINICAL SCENARIO 282 ANSWERS AND RATIONALES 284 CLINICAL SCENARIO ANSWERS AND RATIONALES 299 11 Women’s Health Management 301 QUESTIONS 301 MATERNAL-CHILD CLINICAL SCENARIO 312 ANSWERS AND RATIONALES 314 CLINICAL SCENARIO ANSWERS AND RATIONALES 330 12 Pediatric Health Management 333 QUESTIONS 333 PEDIATRIC CLINICAL SCENARIO 345 ANSWERS AND RATIONALES 347 CLINICAL SCENARIO ANSWERS AND RATIONALES 361 13 Mental Health Management 363 QUESTIONS 363 MENTAL HEALTH CLINICAL SCENARIO 376 ANSWERS AND RATIONALES 378 CLINICAL SCENARIO ANSWERS AND RATIONALES 394 3313_FM_i-xii 14/03/14 5:13 PM Page x TABLE OF CONTENTS xi 14 Case Studies: Care of Clients in Various Settings 397 MEDICAL NURSING CASE STUDY 397 CRITICAL CARE NURSING CASE STUDY 400 OUTPATIENT NURSING CASE STUDY 403 HOME HEALTH CASE STUDY 406 MENTAL HEALTH NURSING CASE STUDY 409 MATERNAL-CHILD CASE STUDY 412 ANSWERS TO CASE STUDIES 414 15 Comprehensive Exam 429 QUESTIONS 429 ANSWERS AND RATIONALES 446 Appendix A: Normal Laboratory Values 469 Glossary of English Words Commonly Encountered on Nursing Examinations 471 Index 475 3313_FM_i-xii 14/03/14 5:13 PM Page xi 1 Introduction to Prioritization, Assignment, Delegation, and Management 1 Each problem that I solved became a rule which served afterwards to solve other problems. —Rene Descartes This book is designed to assist the student nurse in nursing school and in taking nursing examinations, particularly the NCLEX-RN ® exam for licensure as a registered nurse (RN). Prioritization, Delegation & Management of Care for the NCLEX-RN ® Exam focuses on aspects of management such as setting priorities for client care, delegating and assigning nursing tasks, and managing clients and staff. It contains practice questions on these topics in a wide variety of nursing arenas, including medical, surgical, critical care, pediatric, geriatric, rehabilitation, home health, and mental health nursing. Answers—and why each possible response is correct or incorrect—are given for all questions. Management, prioritizing, and delegation questions are some of the most difficult questions for the student and new graduate to answer because there is no reference book in which to find the correct answers. Answers to these types of questions require knowledge of basic scientific principles, standards of care, pathophysiology, and psychosocial behaviors, and leadership qualities and the ability to think critically. It is important to note that the test taker may not always agree with the authors’ rationale for the correct answer. It is poor test taking to read rationales for the incorrect answers; the students will remember reading the rationale but not if the rationale was for the correct or incorrect answer. Many of the answers in this book include tips to help the test taker. Termed “Making Nursing Decisions,” these tips provide help for the student in identifying exactly what the question is asking, in analyzing the question, and in determining the correct response. A Comprehensive Examination with answers and rationales is also included for each field of nursing. Practice questions and answers and practice examinations are valuable in preparing for an examination, but the test taker should remember that there is no substitute for studying the material. (For general information on how to prepare for an examination and on the types of questions used in nursing examinations, refer to Fundamentals Success: A Q&A Review Applying Critical Thinking to Test Taking by Patricia Nugent, RN, MA, MS, EdD, and Barbara Vitale, RN, MA.) NCSBN BLUEPRINT FOR QUESTIONS The National Council of State Boards of Nursing (NCSBN) provides a blueprint that assists nursing faculty in developing test questions for the NCLEX-RN ®. Content included in management of care provides and directs nursing care that enhances the care delivery setting to protect clients, family/significant others, and healthcare personnel. Related content includes, but is not limited to, advance directives, advocacy, case management, client rights, collaboration with the interdisciplinary team, delegation, establishing priorities, ethical 3313_Ch01_001–006 14/03/14 4:45 PM Page 1 practice, informed consent, information technology, and performance improvement. Other topics also include legal rights and responsibilities, referrals, resource management, staff education, supervision, confidentiality/information security, and continuity of care. The questions in this book follow this blueprint. GUIDELINES FOR MAKING A DECISION Nurses* base their decisions on many different bodies of information in order to arrive at a course of action. Among the basic guidelines to apply in nursing practice—and in answering test questions—are the nursing process and Maslow’s Hierarchy of Needs. The Nursing Process One of the basic guidelines to apply in nursing practice is the nursing process, which consists of five steps—assessment, nursing diagnosis, planning, intervention, and evaluation—usually completed in a systematic order. Many questions can be answered based on “assessment.” If a priority-setting question asks the test taker which step to implement first, the test taker should look for an answer that would assess for the problem discussed in the stem of the question. EXAMPLE 2 PRIORITIZATION, DELEGATION, AND MANAGEMENT OFCARE FOR THE NCLEX-RN® EXAM In this book, the term “nurse,” unless otherwise specified, refers to a licensed registered nurse (RN). An RN can assign tasks to an LPN or delegate to unlicensed assistive personnel (UAP), which may be known under other terms such as medical assistant or nurse’s aide. An LPN can delegate tasks to UAP. Each state will have specific regulations that govern what duties/tasks can be delegated/assigned to each of these types of personnel. The term “healthcare provider,” as used in this book, refers to a client’s primary provider of medical care. It includes physicians (including osteopathic physicians), nurse practitioners (NPs), and physician assistants (PAs). Depending on state regulations, many NPs and some PAs have prescriptive authority at least for some categories of prescribed drugs. The nurse is caring for a client diagnosed with congestive heart failure who is currently complaining of dyspnea. Which intervention should the nurse implement first? 1. Administer furosemide (Lasix), a loop diuretic, IVP. 2. Check the client for adventitious lung sounds. 3. Ask the respiratory therapist to administer a treatment. 4. Notify the healthcare provider. Answer: 2 Checking for adventitious lung sounds is assessing the client to determine the extent of the client’s breathing difficulties causing the dyspnea. There are numerous words, such as “check,” that can be used to indicate assessment. The test taker should not discard an option because the word “assess” or “assessment” is not used. Alternatively, the test taker shouldn’t assume that an option is correct merely because the word “assess” is used. The test taker must also be aware that the assessment data must match the problem stated in the stem, regardless of terminology. The nurse must assess for the correct information. If option 2 in the above example said, “Assess urinary output,” it would not be a correct option even though it includes the word “assess,” since urinary output is not related to heart failure or breathing difficulties. In addition, the test taker should be aware that assessment is not always the correct answer when the question asks which should be done first. Suppose, for example, that the above question had listed option 3 as “Apply oxygen via nasal cannula at 2 LPM.” In that case, assessment does not come first. The nurse would first attempt to relieve the client’s distress and then assess. When a question asks what a nurse should do next, the test taker should determine from the information given in the question which steps in the nursing process have been completed and then choose an option that matches the next step in the nursing process. 3313_Ch01_001–006 14/03/14 4:45 PM Page 2 EXAMPLE INTRODUCTION The client diagnosed with peptic ulcer disease has a blood pressure of 88/42, an apical pulse of 132, and respirations are 28. The nurse writes the nursing diagnosis “altered tissue perfusion related to decreased circulatory volume.” Which intervention should the nurse implement first? 1. Notify the laboratory to draw a type & crossmatch. 2. Assess the client’s abdomen for tenderness. 3. Insert an 18-gauge catheter and infuse lactated Ringer’s. 4. Check the client’s pulse oximeter reading. Answer: 3 1. Notifying the laboratory for a type & crossmatch would be an appropriate intervention since the client is showing signs of hypovolemia, but it is not the first intervention because it would not directly support the client’s circulatory volume. 2. The stem of the question has provided enough assessment data to indicate the client’s problem of hypovolemia. Further assessment data are not needed. 3. The vital signs indicate hypovolemia, which is a life-threatening emergency that requires the nurse to intervene to support the client’s circulatory volume. The nurse can do this by infusing lactated Ringer’s. 4. A pulse oximeter reading would not support the client’s circulatory volume. The nurse has assessed the client and formulated a nursing diagnosis. The next step in the nursing process is implementation. The nurse should proceed to a nursing intervention appropriate to the situation. These types of questions are designed to determine if the test taker can set priorities in client care. Maslow’s Hierarchy of Needs If the test taker has looked at the question and the nursing process can’t help in determining the correct option, then using a tool such as Maslow’s Hierarchy of Needs (Fig. 1-1) can assist in choosing the correct answer. Remember that the bottom of the pyramid—physiological needs—represents the top priority in instituting nursing interventions. If a question asks the test taker to determine which is the priority intervention and a physiological need is listed among the options, then that is the priority. If a physiological need is not listed, safety and security take priority, and so on up the pyramid. SelfActualization Esteem and Self Respect Belongingness and Affection Safety and Security Physiological Needs Figure 1–1. Maslow’s Hierarchy of Needs. CHAPTER 1 I NTRODUCTION TOPRIORITIZATION, ASSIGNMENT, DELEGATION, AND MANAGEMENT 3 3313_Ch01_001–006 14/03/14 4:45 PM Page 3 TYPES OF QUESTIONS Most of the questions on the NCLEX-RN ® are multiple choice. The questions involve prioritizing client care, delegating staff tasks, and managing issues dealing with clients and staff. These questions may include interpreting medication administration records (MARs), knowing when notifying the primary healthcare provider (HCP) is priority, and knowing which tasks can be assigned to a licensed practical nurse (LPN) or unlicensed assistive personnel (UAP) and which must be performed by a registered nurse (RN). Some questions on the NCLEX-RN® are termed alternate-format questions and including choosing more than one option that correctly answers a question, ranking procedures or actions in correct order, drop-and-drag questions, and fill-in-the-blank questions. EXAMPLE 4 PRIORITIZATION, DELEGATION, AND MANAGEMENT OFCARE FOR THE NCLEX-RN® EXAM The nurse is assigning tasks to the UAP. Which is an appropriate delegation to the UAP? Select all that apply. 1. Check the area around an incisional wound for redness. 2. Help a client with an upper limb cast to eat. 3. Assist a patient recovering from a hysterectomy to walk to the bathroom. 4. Explain to a client being discharged how to empty and clean the colostomy. 5. Transport a client with a suspected fractured tibia to the x-ray department. Prioritizing Questions/Setting Priorities In test questions that ask the nurse which action to take first, two or more of the options will be appropriate nursing interventions for the situation described. When choosing the correct answer, the test taker must decide which intervention should occur first in a sequence of events, or which intervention directly impacts the situation. With a question that asks which client should the nurse assess first, the test taker should first look at each option and determine if the signs/symptoms the client is exhibiting are normal or expected for the disease process; if so, the nurse does not need to assess that particular client first. Second, if two or more of the options state signs/symptoms that are not normal or expected for the disease process, then the test taker should select the option that has the greatest potential for a poor outcome. Each option should be examined carefully to determine the priority by asking these questions: • Is the situation life threatening or life altering? If yes, this client is the highest priority. • Is the situation unexpected for the disease process? If yes, then this client may be priority. • Is the data presented abnormal? If yes, then this client may be priority. • Is the situation expected for the disease process and not life threatening? If yes, then this client may be—but probably is not—priority. • Is the situation/data normal? If yes, this client can be seen last. The test taker should try to make a decision pertaining to each option. On pencil-andpaper examinations, it may be helpful to note the decision near the option. On a computerized test, the test taker should make the decision and move on to the next question. Delegating and Assigning Care Although each state and province has its own Nursing Practice Acts, there are some general guidelines that apply to all professional nurses. • When delegating to an unlicensed assistive personnel (UAP), the nurse may not delegate any activity that requires nursing judgment. These include assessing, teaching, evaluating, or administering medications to any client and the care of any unstable client. • When assigning care to an LPN, the RN can assign the administration of some medications but cannot assign assessing, teaching, or evaluating any client and cannot delegate the care of an unstable client. 3313_Ch01_001–006 14/03/14 4:45 PM Page 4 Management Decisions The nurse is frequently called upon to make decisions about staffing, movement of clients from one unit to another, or handling conflicts as they arise. Some general guidelines for answering questions in this area include the following: • The most experienced nurse gets the most critical client. • A graduate nurse can take care of any client who is receiving care from a student with supervision. • The most stable client can move or be discharged; whereas, the most unstable client must move to intensive care unit (ICU) or stay in ICU. When the nurse must make a decision regarding a conflict in the nursing station, a good rule to follow is to use the chain of command. The primary nurse should confront a peer (another primary nurse) or a subordinate unless the situation is illegal (such as stealing drugs). The primary nurse should use the chain of command in situations that address superiors (a manager or director of nursing); then the nurse should discuss the situation with the next in command above the superior. PUTTING THE PIECES TOGETHER The nurse is required to acquire information, analyze the data, and make inferences based on the available information. Sometimes this process is relatively easy and at other times the pieces of information do not seem to fit. This is precisely where critical thinking and nursing judgment must guide in making the decision.