Assignment / Delegation / Prioritization/ Ethics

Question 1

While caring for a client in skeletal traction, which tasks can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) to help prevent immobility hazards? Select all that apply.

1. Assist with active and passive ROM exercises
2. Change bed linens while logrolling client from side to side
3. Check color and temp of affected extremity
4. Remind client to use incentive spirometer
5. Reapply penumatic compression device after bathing the client

Answer 1

When providing care for a stable client, the RN can safely delegate these tasks to the UAP:

Assist with active and passive ROM exercises after the client has been taught how to perform them by the RN or physical therapist (Option 1)
Notify the RN of client reports of pain, tingling, or decreased sensation in the affected extremity
Remind the client to use the incentive spirometer after the client has been taught proper use by the RN or respiratory therapist (Option 4)
Maintain proper use of pneumatic compression devices (Option 5)
Remind the client to move frequently using the overhead trapeze

Not 2 because log rolling requires multiple staff members. Clients are instructed to lift themselves using the overhead trapeze when changing linens.

Not 3 because the RN is responsible for peripheral circulation assessments.

Question 2

The unit is staffed with an experienced registered nurse, an experienced licensed practical nurse, and unlicensed assistive personnel (UAP). Which tasks can the charge nurse appropriately delegate to UAP? Select all that apply.

1. Apply protective skin ointment after perineal cleansing
2. Determine if a client has adequate relief after administration of an analgesic
3. Document daily weight
4. Feed a client who had a stroke 24 hrs ago
5. Perform ROM exercises for a client on a ventilator

Answer 2

Answer: 1, 3, 5

UAP can perform active and passive range-of-motion exercises (Option 5). Under the direction of the RN, UAP can apply protective ointment (such as zinc oxide) after cleaning a client (Option 1).

The UAP can obtain objective data such as the client’s height and weight (Option 3)

UAP can not evaluate (Option 2)

A stroke it not considered stabilized until approximately 48 hours have passed without changes. (Option 4)

Question 3

Which of the following clients require interventions by RN?

1. A client receiving a blood transfusion who reports severe anxiety and has BP 90/60 mm Hg and a pulse of 110/min
2. A client who had metoprolol and HR decreased to 60/min
3. A client’s BP decreased from 130/80 to 110/70 after hydromorphone admin
4. A client’s BP was 90/65 before nifedipine was administered
5. A client’s pulse increased from 70/min to 100/min after albuterol admin

Answer 3

Answer: 1, 4

Option 1: Blood transfusion reaction (decreased BP)
Option 4: CCBs should be held for a low BP because CCBs will lower the BP even more!

Option 2: its expected for the HR to drop after the client takes a beta blocker

Option 3: Hydromorphone will vasodilator and a decrease in BP is expected

Option 5: Albuterol is a beta-adrenergic agonist used for bronchospasm. It also stimulates beta receptors in the heart, causes a rise in HR.

Question 4

A health care provider is screaming at the nurse in the hallway, “Why didn’t you get that surgery scheduled sooner?” What is the best response by the nurse?

1. “I am sorry, I will get this fixed and schedule the surgery immediately.”
2. “I am uncomfortable with your tone; please excuse me while I locate my supervisor”
3. “I delegated this task to the UAP; please follow up with them”
4. “I think you are overreacting; you should have specified the day and time”

Answer 4

2. “I am uncomfortable with your tone; please excuse me while I locate my supervisor”

Lateral violence (ie, horizontal violence) can be defined as acts of aggression carried out by a coworker against another coworker and designed to control, diminish, or devalue a colleague. Violence in the workplace should not be tolerated or ignored by either staff or management.

The nurse should use assertive communication, which uses a direct approach to minimize miscommunication, and inform the health care provider in a professional manner that the behavior will not be tolerated. In addition, the incident should be reported to the immediate supervisor (Option 2).

Question 5

Who should the nurse assess first?

1. Client with chronic anxiety disorder taking buspirone and diphenhydramine who has a dry mouth
2. Client with chronic heart failure taking metoprolol and lisinopril who has dizziness when standing up
3. Client with major depressive disorder taking phenelzine and pseudoephedrine who has a headache
4. Client with DM II taking metformin and lovastatin who has upset stomach and nausea

Answer 5

3. Client with major depressive disorder taking phenelzine and pseudoephedrine who has a headache

Phenelzine = MAOI
Pseudoephedrine = nasal decongestant (increases BP) 

A combination of these two meds may lead to a hypertensive crisis! Headache is a common early symptom of hypertensive crisis that should be evaluated immediately in clients taking MAOIs.

Question 6

The nurse assesses and reviews the laboratory results for 4 clients. Which client’s fever is of highest priority and should be reported to the HCP immediately?

1. Client newly diagnosed with Hodgkin lymphoma scheduled for chemotherapy who has a fever of 38.3 C and WBC of 6000
2. Acute cholecystitis scheduled for surgery who has a fever of 38.9 and WBC of 13000
3. Client w/ C.diff on metronidazole with a fever of 38.3 C and WBC 18000
4. Client with colon cancer receiving chemotherapy who has a fever of 38 C and WBC of 1500

Answer 6

4. Client with colon cancer receiving chemotherapy who has a fever of 38 C and WBC of 1500

Client on chemotherapy = bone marrow suppression –> immunosuppression.
A fever can signal an infection and, in the presence of neutropenia (ie, neutropenic fever), can rapidly develop into life-threatening sepsis. Even a low-grade fever should be taken seriously in these clients.

I picked Option 2. Thinking if the client has a fever / infection going into surgery. Which is contraindicated. But the client with neutropenia and infection is the priority!

Question 7

A client is brought to the emergency department after his face slammed into a brick wall during a gang fight. Which client assessment finding is most important for the nurse to consider before inserting a nasogastric tube?

1. An ecchymotic area on the forehead
2. Frontal headche rated as 10 on a 1 - 10 scale
3. Nasal drainage on gauze has a red spot surrounded by serous fluid
4. Small amount of bright red blood oozing from cheek laceration

Answer 7

3. Nasal drainage on gauze has a red spot surrounded by serous fluid

The serous fluid indicates cerebral spinal fluid (Cerebralspinal fluid rhinorrhea).

Identification of this pattern is very important as CSF leakage places the client at risk for infection. The client’s nose should not be packed. No nasogastric or oral gastric tube should be inserted blindly when a basilar skull fracture is suspected as there is a risk of penetrating the skull through the fracture site and having the tube ascend into the brain.

Question 8

Which client should the nurse assess first?

1. Client with acute kidney injury scheduled for hemodialysis has urine output of 200mL in 8 hrs
2. Client with indwelling urinary catheter 1 day post op prostatectomy reports severe bladder spasms
3. Client with an ureteral stent placed this morning after laser lithotripsy reports burning on urination and hematuria
4. Client with spinal cord injury (above T6) requiring intermittent catheterization reports a throbbing headache and nausea

Answer 8

4. Client with spinal cord injury (above T6) requiring intermittent catheterization reports a throbbing headache and nausea

This client has autonomic dysreflexia!

Common triggers include bladder or rectum distention and pressure ulcers. Characteristic manifestations include acute onset of throbbing headache, nausea, and blurred vision; hypertension and bradycardia; and diaphoresis and skin flushing above the level of the injury. It is a medical emergency that requires immediate intervention (eg, bladder catheterization) to remove the precipitating trigger.

Question 9

Nausea and vomiting in which client is of greatest concern to the nurse?

1. Client with postoperative opthalmic surgery
2. Client receiving chemotherapy
3. Client with Meniere disease
4. Client with severe gastoenteritis

Answer 9

1. Client with postoperative opthalmic surgery

Increased intraocular pressure can cause damage to the blood vessels and retina and cause potential permanent vision loss.

Coughing, vomiting, straining to lift objects (>5 lb), and bending at the waist temporarily increase intraocular pressure and must be avoided after eye surgery.

Antiemetic medication is administered as needed following ophthalmic surgery to prevent vomiting.

Question 10

A nurse in the emergency department is caring for a homeless client just brought in with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client’s plan of care?

Select all that apply.

1. Apply occlusive dressing after rewarming
2. Elevate affected extremities after rewarming
3. Massage area to increase circulation
4. Provide adequate analgesia
5. Provide continuous warm water soaks

Answer 10

Answer: 2, 4, 5

Don’t massage site! Damages tissues

Immerse the affected area in water heated to 98.6-102.2 F (37-39 C), preferably in a whirlpool. Higher temperatures do not significantly decrease rewarming time but can intensify pain (Option 5).

Provide analgesia as the rewarming procedure is extremely painful (Option 4).

As thawing occurs, the injured area will become edematous and may blister. Elevate the injured area after rewarming to reduce edema (Option 2).

Keep wounds open immediately after a water bath or whirlpool treatment and allow them to dry before applying loose, nonadherent, sterile dressings (Option 1).

Question 11

The home health nurse is providing long-term care to several clients. Which are examples of inappropriately crossing professional boundaries?

Select all that apply.

1. Accepting a gold bracelet from a client
2. Making a visit to the hospital after a client has surgery
3. Offering to pray together
4. Sending a sympathy card
5. Soliciting a wealthy client to invest in a company
6. Staying after work hours and drinking wine with a client

Answer 11

Answer: 1, 5, 6

The nurse should always put the client’s needs first and never seek personal gain (eg, accepting gift worth >$20, asking for financial investment/loan) (Options 1 & 5).

The nurse should follow a facility’s policy on professional standards of behavior. In the absence of a formal policy, the nurse should consider if the action would be appropriate to include in the medical record. If the nurse is unsure, it may be indicative of a violation of professional boundaries (eg, flirting with client, consuming alcoholic beverages with client) (Option 6).

(Option 2 - I picked) An occasional visit to a previous client in a different circumstance (hospital, nursing home) is considered appropriate and caring.

Question 12

The home health nurse is providing care for a 6-year-old client who has a tracheostomy and is being mechanically ventilated when the ventilator’s apnea alarm sounds. The nurse finds the client to be unresponsive and pulseless, and there are no other caregivers present. Which action should the nurse take first?

1. Begin chest compression
2. Deliver 2 breaths using a bag valve device
3. Locate and apply an automated external defibrillator
4. Call 911

Answer 12

1. Begin chest compression

If the nurse is a single rescuer in a witnessed cardiac arrest of a pediatric client, the first action is to promptly initiate CPR, starting with chest compressions (Option 1).

Chest compression should be given first before rescue breaths (Option 2)

If the nurse is still alone after 2 minutes (~5 cycles) of CPR, it is appropriate to pause CPR to activate the emergency response system and obtain the automated external defibrillator, if available (Options 3,4)

Question 13

The nurse receives the handoff of care report on four clients. Which client should the nurse see first?

1. Client has 8/10 pain with resp of 25/min who had a right pneumonectomy 12 hrs ago
2. Client with a left pleural effusion who has crackles, absent breath sounds in the left base, and an SpO2 of 94% on RA
3. Client with a temp of 38 C and rep rate of 12/ min who had a small bowel resection 1 day ago
4. Client with pneumonia who has a temp of 36.4, SpO2 93% on 4L and is becoming restless

Answer 13

4. Client with pneumonia who has a temp of 36.4, SpO2 93% on 4L and is becoming restless

This client has signs of acute respiratory failure.

Acute respiratory failure (ARF) is a life-threatening impairment of the lungs’ ability to oxygenate blood and excrete carbon dioxide (CO2). ARF may occur from exacerbation of chronic (eg, chronic obstructive pulmonary disease, asthma) or acute (eg, pneumonia, pulmonary edema) illnesses.

Nurses assessing for signs of ARF should consider both respiratory and neurological manifestations. Altered mental status (eg, confusion, agitation, somnolence) is a common and often overlooked symptom that may occur because of the brain’s sensitivity to inadequate oxygenation and alterations in acid-base balance from retained CO2 (Option 4).

(Option 3 - I picked) Low-grade fever may occur following surgery (due to the release of inflammatory cytokines) or from postoperative atelectasis. The client should be encouraged to ambulate and deep-breathe.

Question 14

The nurse is working on a busy medical-surgical unit and is responding to the client call lights. Which statement would be the priority to assess first?

1. A 65 y/o female client started on celecoxib says “I have nausea and my upper back and shoulder and hurting quite a bit”
2. A client’s child says: “my parent has been here for 2 days without anything to eat or drink”
3. A paraplegic client with multiple stage 4 pressure ulcer says “I have had a bowel movement and need to be cleaned up”
4. A post op client says I am very nauseous and I threw up. This pain med is making me really sick

Answer 14

1. A 65 y/o female client started on celecoxib says “I have nausea and my upper back and shoulder and hurting quite a bit”

Celecoxib - has a black box warning for increased risk of cardiovascular complications.

The female client has vague symptoms of MI: Nausea, upper back and shoulder pain.

Therefore, this client is the priority to assess first.