Priority, Delegation & Management Questions (N460) – Flashcards

1. The client who has just been brought to the unit from the emergency department (ED) with no report of complaints. This client may or may not be stable. The client may have "no complaints" at this time, but the nurse must assess this client first to determine whatever the complaint was that brought the client to the ED has stabilized. This client should be seen first. 2. It is important for the nurse to assess for pain relief in a timely manner, but this client has been medicated and the pain was a 3. The nurse can evaluate the amount of pain relief after making sure that the ED admission is stable. 3. This client has been back from the procedure and a bilateral pedal pulse indicates the client is stable; therefore, this client does need to be seen first. 4. Psychological issues are important, but not more so than a physiological issue, and the client admitted from the ED may have a physiological problem.

3. The antidysrhytmic to the client in ventricular fibrilation. The client in ventricular fibrillation is in a life-threatening situation; therefore, the antidysrhythmic, such as lidocaine or amiodorone, should be administered first. 1. The cardiac glycoside, such as digoxin, should not be administered unless the apical pulse is 60 or above. 2. Because the client's serum K+ level is already low, the nurse should question administering a loop diuretic. 4. The client's blood pressure is above 90/60, so the calcium-channel blocker can be administered but it is not priority over a client who is in a life-threatening situation.

4. The client diagnosed with CHF who has pink frothy sputum. The client would not expect the client with congestive heart failure to have pink, frothy sputum because this is a sign of pulmonary edema. This client should be assessed first. 1. The nurse would expect the client with a deep vein thrombosis to have an edematous right calf, so the nurse would not need to assess this client first. 2. The nurse would expect the client with mitral valve stenosis to have heart palpitations (sensa- tions of rapid, fluttering heartbeat). 3. The nurse would expect the client with arterial occlusive disease to have intermittent claudication (leg pain), so the nurse would not need to assess this client first.

3. The 75-year-old client scheduled for a cardiac catheterization. A new graduate should be able to complete a pre-procedural checklist and get this client to the catheterization lab. 1. This client is at high risk for complications related to necrotic myocardial tissue and will need extensive teaching; therefore, this client should not be assigned to a new graduate. 2. Unstable angina means this client is at risk for life-threatening complications and should not be assigned to a new graduate. 4. This patient could be having a heart attack so not appropriate.

3. Assign a UAP to complete am care. A UAP is capable of performing the morning care. This is an appropriate nursing task to delegate. 4. Writing a care plan for a client requires nurs- ing judgment; therefore, an RN should be assigned this function. 1. An LPN can perform sterile procedures such as inserting indwelling catheters and IV catheters. An RN should perform the functions that require nursing judgment, such as planning and evaluating the care of the clients. 2. Although an LPN could administer most in- travenous piggyback (IVPB) medications, only qualified RNs may administer intravenous push (IVP) medications and chemotherapy. 4. Writing a care plan for a client requires nurs- ing judgment; therefore, an RN should be assigned this function.

2. Provide the case manager with any information that is required for continuity of care. The case manager's job is to ensure continuity and adequacy of care for the client. This individual has a "need to know." 1. Unless the information shared is directly connected to healthcare issues, the nurse should not share confidential information with any- one else. The nurse should inform clients that information directly affecting the client's healthcare will be shared on a need-to-know basis only. 3. The case manager is part of the healthcare team; therefore, information should be shared. 4. The client gave permission when being admit ted to the hospital for information to be shared among those providing care. The case manager does not need to obtain further consent.

2. Check the client's telemetry leads. The UAP should be instructed to check the telemetry lead placement; this reading cannot be ventricular fibrillation because the client is talking to the nurse over the intercom system. 1. The telemetry strip indicates an artifact, so there is no need for the UAP or any staff member to call a Code Blue, which is used when someone has arrested. 2. This telemetry is an artifact; therefore, the leads should be checked and the UAP can do this because the client is stable. 3. The UAP can take care of this problem; there is no need for the primary nurse to check the client. 4. The strip indicates an artifact, but there is no indication that the client should be removed from telemetry.

2. The nurse who just transferred from critical to the cardiac unit. The nurse with critical care experience would be the best choice to float to the emergency department. 1. The nurse who just has surgical nursing expe- rience would not be the choice to float to the emergency department. 2. The nurse with critical care experience would be the best choice to float to the emergency department. 3. The nurse just returning from sick leave would not be a good choice to send to the emergency department, which may be very busy at times. 4. This nurse has not had experience in critical care; therefore, this nurse would not be the best choice to float to the emergency department.

1. The client with CAD who is complaining the nurses are being rude and won't answer call lights. The charge nurse is responsible for all clients. At times it is necessary to see clients with a psychosocial need before other clients who have situations that are expected and are not life threatening. 2. An elevated CPK-MB, cardiac isoenzyme, level is expected in a client with an acute myocardial infarction; therefore, the charge nurse would not see this client first. 3. The INR is within the normal limits of 2 to 3; therefore, this client does not need to be assessed first. 4. This client is being transferred to the cardiac unit; therefore, the client is stable and does not need intervention.

1. Discontinue the client's vasoconstrictor, dopamine. The nurse should first discontinue the medication that is causing the increase in the client's blood pressure prior to doing anything else. 2. The nurse should notify the HCP but not prior to taking care of the client's elevated blood pressure. 3. The client may need a medication to de crease the blood pressure but the nurse should first discontinue the medication causing the elevated blood pressure. 4. The nurse must first decrease the client's blood pressure prior to assessing the client.

3. The client who is showing multifocal premature ventricular contractions (PVCs). Multifocal PVCs are an emergency and are possibly life threatening. An experienced nurse should care for this client. 1. The client with rheumatic heart fever is expected to have carditis and should be on bed rest. The nurse needs to talk to the client about the importance of being on bed rest but this client is not in a life-threatening situation and does not need the most experienced nurse. 2. These ABG values are within normal limits; therefore, a less experienced nurse could care for this client. 4. A cardiac catheterization is a routine procedure and would not require the most experienced nurse.

4. This client is at risk for choking and is not stable; therefore, the charge nurse should intervene and not allow the UAP to feed this client. 1. All clients in the ICU are on telemetry, and the UAP could bathe the client. This would not warrant intervention by the charge nurse. 2. The UAP can perform glucometer checks at the bedside, and there is nothing that indi cates the client is unstable. This would not warrant intervention by the charge nurse. 3. The UAP can assist with helping the client sit up for a portable chest x-ray as long as the UAP is not pregnant and wears a shield.

1. The client receiving a calcium channel blocker (CCB) who is drinking a glass of grapefruit juice. The client receiving a CCB should avoid grapefruit juice because it can cause the CCB to rise to toxic levels. Grapefruit juice inhibits cytochrome P450-3A4 found in the liver and the intestinal wall. This inhibition affects the metabolism of some drugs and can, as is the case with CCBs, lead to toxic levels of the drug. For this reason, the nurse should investigate any medications the client is taking if the client drinks grapefruit juice. 2. The apical heart rate should be greater than 60 beats/minute before administering the medication; therefore, the nurse would not question administering this medication. 3. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be taken with foods to pre- vent gastric upset; therefore, the nurse would not question administering this medication. 4. The INR therapeutic level for warfarin (Coumadin), an anticoagulant, is 2 to 3; therefore, the nurse would not question administering this medication.

2. The charge nurse discovers that the staff nurse is having problems with child care; therefore, the charge nurse allows the staff nurse to work a 9:00 a.m. to 9:00 p.m. shift. This is a win-win strategy that focuses on goals and attempts to meet the needs of both parties. The charge nurse keeps an experienced nurse and the staff nurse keeps her position. Both parties win 1. This is a win-lose strategy wherein, during the conflict, one party (charge nurse) exerts dominance and the other (staff nurse) submits. 3. This is negotiation in which the conflicting parties give and take on the issue. The staff nurse gets one more chance and the charge nurse's authority is still intact. 4. This is not an example of a win-win strategy and is not an appropriate action for the staff nurse to take. The opinion of the staff should not influence the charge nurse's action.

4. The client diagnosed with atherosclerosis who has slurred speech and drooling. Slurred speech and drooling are signs of a cerebrovascular accident (stroke or brain attack) and is not normal for a client with atherosclerosis; therefore, this client should be assessed first. 1.The client with pericarditis is expected to have chest pain with inspiration; therefore, this client does not warrant immediate intervention. 2. The client with mitral valve regurgitation is expected to have thready peripheral pulses and cool, clammy extremities. Therefore, this client does not warrant immediate intervention. 3. The client with Marfan syndrome is expected to have a chest that sinks in or sticks out, known as funnel chest or pectus excavatum; therefore, this client does not warrant imme- diate intervention. 4. Slurred speech and drooling are signs of a cerebrovascular accident (stroke or brain attack) and is not normal for a client with atherosclerosis; therefore, this client should be assessed first.

2. Check to see what the client has eaten in the past 24 hours. Assessing the client's intake will help the nurse to determine the extent of the client's complaints. This is the first intervention. 1. The family may be allowed to bring in food occasionally from home, but what they bring may not adhere to a low-sodium diet, and the family should not be required to provide three meals per day for the client. This is the facility's responsibility. 3. This may be true but does not help the client adjust to a lack of sodium in the diet. 4. A referral to the dietician should be made after the nurse fully assesses the client.

3. The client diagnosed with fulminant pulmonary edema. A client with fulminant pulmonary edema is experiencing an acute, life-threatening problem. The most experienced nurse should be assigned to this client. 1. The client with mitral valve stenosis can live with this diagnosis and it is not a life- threatening condition. 2. The client with asymptomatic sinus brady cardia is stable and because the client is not exhibiting any signs/symptoms, this client does not need to be assigned to the most experienced nurse. 4. A client with acute atrial fibrillation is not in a life-threatening situation; therefore, this client would not be assigned to the most experienced nurse.

3. Instruct the UAP to get the crash cart. The nurse can tell the UAP to get the crash cart while the nurse assesses the client. This is the best task to assign the UAP at this time because this client may be unstable and until that is deter mined, the nurse should not delegate any client care. 1. The first step in cardiopulmonary resuscitation according to the AHA guidelines is to establish unresponsiveness by "shaking and shouting." If the client does not respond to being shaken, then the nurse can proceed to the next step, which is to "look, listen, and feel" for breaths. This is assessment and, according to AHA guidelines, the UAP could perform this function if alone. How ever, the nurse should assess the client before a UAP. 2. Administering chest compressions is per formed after establishing unresponsiveness and lack of respiration. 4. The nurse should place the client in the recumbent position before attempting to perform chest compressions; the nurse

1. Are you sexually active? The nurse should be aware that sexual activity is important to most adults and should not decide that the client is not sexually active because of a client's age. The nurse should provide instructions regarding sexual activity before the client is discharged. This is the question that should be asked because many clients may be embarrassed to bring up the subject. 2. The client should not drive a motor vehicle until released to do so by the healthcare provider (HCP). This is not an appropriate question at this time. 3. The client should be discharged with a prescription for oral pain medications to be taken as directed by the surgeon. The nurse should not encourage the client to use old medications the client may have at home. This is not an appropriate question. 4. The nurse is providing discharge instructions and should tell the client when to call the healthcare provider (HCP). This is not an appropriate question.

1, 2, 3, 5. 1. Case managers help coordinate health care between multiple sources of healthcare attempting to contain healthcare cost. 2. The case manager is a client advocate and helps with communication between the client and healthcare providers, which, it is hoped, enhances the client's quality of life. 3. The case manager coordinates out patient care and in-patient care, and helps with referrals for the client.5. The case manager is involved in assessing, planning, facilitating, and advocating for health services for a client, which, it is hoped, provide quality care. Trying to coordinate this is often exhausting and frustrating for the client and family. 4. Case management is not a form of health insurance.

3. The director of nurses terminates the UAP, explaining that all staff must be on time so that the clinic runs smoothly. This is a win-lose strategy during which the conflict shows one party (the director of nurses) exerts dominance and the other party (UAP) must submit and loses. 1. This is a win-win strategy that focuses on goals (to have adequate staff) and attempts to meet the needs of both parties. The director of nurses keeps an experienced nurse, and the UAP keeps her position. Both parties win. 2. This is a possible win-win strategy in which both parties win. The UAP keeps her job, and the director of nurses can hire a UAP who will be able to work the assigned hours. 4. This is a negotiation in which the conflicting parties give and take on the issues. The UAP gets one more chance, and the director of nurse's authority is still intact.

3. Explain to the UAP, in private, that this is an inappropriate comment and violates HIPAA. The clinic nurse should correct the UAP's behavior, but it should be done in private and with an explanation as to why the action is inappropriate. This is a violation of confidentiality because the scale is located in the office area and any client or visitor passing by, as well as other staff members, can hear the comment. 1. The clinic nurse should not correct the UAP in front of the client. This is embar- rassing to the UAP and makes the client uncomfortable. 2. The clinic nurse must correct the UAP's be- havior. The client's weight gain should not be announced in the office area so that all staff, clients, and visitors can hear. This is a violation of confidentiality. 4. The clinic nurse should handle this situation. If the UAP's behavior shows a pattern of behavior, then it should be reported to the director of nurses.

3. Change the sharps container as per clinic policy. A full sharps container is a violation of Occupational Health and Safety Administration (OSHA) regulations and may result in a $25,000 fine. The nurse should first take care of this situation immediately and then discuss it with the UAP. This is modeling appropriate behaviour 1. A full sharps container is a violation of Occupational Health and Safety Administra tion (OSHA) regulations, and because the UAP has not done it after being asked twice, a third request is not necessary. 2. The nurse should discuss why the sharps container has not been changed, but it is not the first intervention. 4. The situation should be documented because the UAP was told twice, but documentation is not the first intervention.

2. Tell the wife to have the client chew an aspirin. The AHA recommends the client having chest pain chew an aspirin to help de crease platelet aggregation. This is the first intervention the clinic nurse should tell the wife to do. The client is in dis tress; therefore, the nurse should have the wife do something. 1. The wife should call 911, but the American Heart Association recommends chewing a baby aspirin at the onset of chest pain. 3. This question could be asked to determine whether the pain is secondary to a gallblad- der attack or gastric irritation, but this is not the first intervention. 4. The clinic nurse could possibly talk to the client while the wife is getting an aspirin, but this is not the first intervention.

4. The client with chronic atrial fibrillation is at risk for pulmonary emboli, a poten tially life-threatening complication. Chest pain is a common symptom of pulmonary embolism. The nurse should contact this client first. 1. This blood pressure—148/92—is elevated, but it would not be life threatening for someone diagnosed with hypertension; therefore, the nurse would not contact this client first. 2. A pulse oximeter reading of 93% is low but still within normal limits, and a client with cystic fibrosis, a chronic respiratory condi- tion, would be expected to have a chronically low oxygen level. This client would not need to be contacted first. 3. The client with CHF would be expected to have edematous feet; this client would not need to be contacted first.

1. Assist client to a sitting position. The nurse's first intervention is to assist the client to a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. This will, it is hoped, help relieve the client's respiratory distress. 2. The nurse should assess the client's vital signs, but the first intervention is to help the client breathe. 3. The nurse should contact the paramedics if the client does not improve after being placed in a sitting position, but this is not the nurse's first intervention. 4. The nurse should auscultate the client's lungs, but the first intervention is to help the client breathe more easily.

2. "You should not go out with him as long as she is a client of our agency." This statement protects the HH aide. This is professional boundary crossing. The employee should not date any relatives of the client because this may pose a conflict of interest. The HH aide should wait until the client is no longer on service. 1. This is professional boundary crossing. Even though the grandson is not the client, he is related to the client. The HH aide should not go out with him. 3. The nurse's best response is to tell the HH aide the facts about dating relatives of clients. The director would tell the HH aide the same information. 4. The HH aide could date the grandson when the client is no longer on service. So this statement is not the nurse's best response.

3. Assess the client's support system. The client's support system is the priority assessment for the hospice nurse. The client will be cared for in the home and the nurse must know who is available to help the client. 1. Assessment of the client's spiritual needs in end-of-life issues is a key consideration but is the chaplain's responsibility, when he/she is a member of the hospice team. 2. The client's financial situation can be as- sessed, but it is not priority over the client's spiritual needs when death is near. 4. The client's medical diagnosis is important when addressing the grieving process but there is nothing the nurse can do about the medical diagnosis, which is why assessing, supporting, and addressing the client's spiritual needs will be carried out prior to the medical diagnosis.

3. Stay with the client and her husband. The nurse should stay with the client and her husband and not make any life- rescuing interventions while the client is dying. The husband should not be left alone. 1. The client's HCP will need to determine time of death but it is not the nurse's first intervention. 2. The Rapid Response Team would not be notified because the client has a DNR. 4. The UAP can perform post-mortem care but it is not the first intervention when the client's husband tells the nurse his wife has quit breathing.

3. The client whose pain is not being controlled with the current medications. One of the main goals of hospice is pain and symptom control. This client should be seen first so that appropriate pain control can be obtained immediately. 1. This client should be seen, but a client who is terminally ill and is refusing to eat is not an emergency situation. 2. The client has a right to rescind the out-of- hospital DNR but paperwork is not priority over a client who is in pain. 4. A Stage 1 pressure ulcer must be assessed and treatment started but this is not priority over pain control.

3. Get the client's medical records and bring them to the client's room. The nurse should immediately go to the client's room and assess the client. Sometimes the nurse may need the client's chart and medical administration record (MAR) to assist in the assessment of findings. The UAP can bring these documents to the room. 1. If the HCP is called, the nurse should per- form this task, not the UAP. A UAP cannot take a telephone order; only a licensed nurse can take telephone orders. 2. The UAP cannot administer a medication, not even Tylenol. 4. The UAP should not be asked to relay such information. This is the nurse's or HCP's responsibility.

2. Assess the client diagnosed with stage IV heart failure. The nurse cannot assign assessment. This is the inappropriate task to assign to the LPN 1. The LPN can feed a client who is stable but unable to feed him or herself because of medical equipment. This is an appropriate task to assign 3. The LPN can discharge a client who had a procedure and who does not require extensive teaching. 4. The LPN can administer a routine IVPB medication.

2. Tell the UAP to answer the other call lights on the unit. Answering the call lights of the other clients on the unit can be delegated to the UAP. 1. The nurse in the client's room notifies the hospital operator of a code situation. 3. In a hospital, the respiratory therapist assumes the responsibility for ventilations. 4. The nursing supervisor is responsible for requesting the family to leave the room. The UAP does not have the authority to make this request.

1. Place the client on a telemetry monitor and assess the client. Federal law requires that clients presenting to an emergency department must be assessed and treated without regard to payment. The nurse should initiate steps to assess the client. 2. The nurse must assess the client. If a transfer is made, it will be after the client has been stabilized and the receiving hospital has ac cepted the transfer. 3. Federal law requires that clients presenting to an emergency department must be assessed and treated without regard to payment. The hospital will attempt to recover the costs after the client has been treated, 4. This is irrelevant information.

1. The client diagnosed with angina who is reporting chest pain. The client with angina should be asymptomatic; when the client is complaining of chest pain, this is abnormal data. Therefore, this client should be assessed first. Remember Maslow's Hierarchy of Needs identifies physiological needs as priority and pain is priority. 2. In a client diagnosed with CHF, 4+ edema is expected. The nurse would not need to assess this client first. 3. The client diagnosed with endocarditis is expected to have a fever. The nurse would not need to assess this client first. 4. The client diagnosed with aortic valve stenosis has the classic triad of syncope, angina, and exertional dyspnea; therefore, this client would not be assessed first.

1. The IVPB antibiotic to the client with endocarditis admitted at 0530 today. First-dose intravenous antibiotic medications are priority medications and should be administered within 1 to 2 hours of when the order was written. This should be the first medication administered. 2. Antiplatelet medication, aspirin, is not a priority medication. 3. A coronary vasodilator patch, nitroglycerin, is not a priority medication. 4. A statin medication that decreases cholesterol level should be administered in the evening when the enzyme for cholesterol metabolism is at its highest peak.

3. The UAP can assist with hygiene needs; this is one of the main tasks that may be delegated to UAPs. 1. The nurse and respiratory therapist, not the UAP, are responsible for monitoring the ABGs. 2. Infusion of blood and blood products, even the client's own, cannot be delegated to a UAP. 4. The nurse must assess the surgical site for bleeding, infection, and healing. The UAP cannot perform assessments.

2. The client who is crying after being informed of a terminal diagnosis. The client has been given devastating news. When all the information in the options is expected and not life threaten ing, then psychological issues have priority. This client should be seen first. 1. This client is being treated, and if the blood is almost finished, then it can be assumed that the client is tolerating the blood without incident. 3. The client has eaten. The nurse could arrange for the dietician to consult with the client about food preferences, but this client does not need to be assessed first. 4. Dyspnea on exertion is not priority if the client is exerting himself or herself.

1. Continue to care for the client's needs as usual. The nurse should care for the client as if the DNR order was not on the chart. A DNR order does not mean the client no longer wishes treatment. It means the client does not want CPR or to be placed on a ventilator if the client's heart stops beating. 2. The information about the DNR status is already inside the chart. It may need to be placed on the outside of the chart and a special armband or other notification made to other healthcare personnel. 3. The client has a DNR order, but this does not imply that there may be 6 months or less life expectancy for the client. (Hospice care may be requested for clients with less than a 6-month life expectancy.) An order for hospice must be written by the attending healthcare provider before making this referral. 4. The client should be allowed as many visitors as the hospital policy allows.