Nursing Roles & Practice Flashcards
What should RNs not delegate?
- Assessment, Diagnosis, Planning and Evaluation of the Nursing Process
- Health Teaching and Counseling
- Complex and Complicated Activities
- Unstable Patients with Unpredictable Outcome
What are the 5 rights to delegation?
Right Task
Right Circumstances
Right Person
Right Communication
Right Supervision
Which assessment findings of a patient with multiple injuries sustained during a head-on car collision takes priority?
A. Unequal pupils
B. A deviated trachea
C. Irregular apical pulse
D. Ecchymosis in the flank area
B. A deviated trachea
Based on Maslow’s hierarchy of needs, which nursing diagnosis is the highest priority?
A. Diarrhea
B. Deficient knowledge
C. Disturbed body image
D. Deficient fluid volume
D. Deficient fluid volume
During the shift, the following events happen at the same time. Indicate the order in which you will attend to these issues.
A. Client A calls for an antiemetic after vomiting bile
B. Client B wants to know when he will be discharged
C. Client C’s family wants to speak to the doctor
D. Client D is walking down the hall, threatening to leave
D, A, C, B
What are the guidelines for prioritization?
Airway: foreign body; swelling in trachea, larynx or airways; drowning,
Breathing: neurological (brain hemorrhage, increased ICP, spinal cord injury, guillian
barre, myasthenia gravis), trauma to chest, pneumothorax, COPD, pneumonia, atelectasis, overdose causing respiratory depression, seizure
Circulation: cardiac failure; low Hgb,Hct; fluid overload or deficit; critical electrolyte
imbalances esp. in renal failure; inadequately treated hypertension; cardiotonic or anticoagulant IV solutions
What are the guidelines for prioritization?
Actual versus Potential: In most cases, an actual problem will take precedence over a potential problem unless the potential problem presents a greater risk to safety than the actual problem. For example, while an alert client may have an actual problem of vomiting, a client who is nauseated while in c-spine precautions is a higher priority because of the concerns for airway safety.
Acute versus Chronic: Given a choice between acute and chronic, an acute situation will almost always be the higher priority. A good example of this would be a client with COPD. While their disease is being maintained with medications and oxygen, they are considered chronic. When there is evidence of respiratory distress or exacerbations of the symptoms (respiratory rate, ABGs, pulse ox, etc.) the client becomes acute by showing a change in their baseline condition.
Least Invasive First: It is important for the nurse to consider less invasive options before increasing the client’s risk of injury with an invasive option. For example, standing a male client at the bedside every two hours to use a urinal is a better option than applying adult diapers. Applying adult diapers is a better option than applying a condom catheter. Applying a condom catheter is a better option than placing a Foley catheter.
Safe Practice: This is always a priority. Safety concerns may include evaluation of the risk for falls, prevention of injury when performing a skill, reduction of risk for hospital acquired infections (HAI), and more
What are Maslow Hierarchy of Needs?
-Physiological needs
-Safety and security
-Love & belonging
-Self-esteem
-Self actualization
You are serving as preceptor to a nurse who has recently graduated and passed the NCLEX. The nurse has only been on the unit for 2 days. Which patient should you assign to the new nurse?
A. A 68-year-old patient with diabetes who is showing signs of hyperglycemia
B. A 58-year-old patient with diabetes who has cellulitis of the left ankle
C. A 49-year-old patient with diabetes who has just returned from post-anesthesia care unit after a below-knee amputation
D. A 72-year-old patient with diabetes with diabetic ketoacidosis who is receiving IV insulin
B. A 58-year-old patient with diabetes who has cellulitis of the left ankle
When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be the most appropriate to assign to an LPN under the supervision of the team leader RN?
A. A patient with severe anemia secondary to GI bleeding
B. A patient who needs enemas and antibiotics to control GI bacteria
C. A patient who just had a bowel resection surgery
D. A patient who needs central line insertion for chemotherapy
B. A patient who needs enemas and antibiotics to control GI bacteria
Which client would you, the RN delegate to an LPN under your supervision?
A. A 25-year-old client admitted yesterday after sustaining a concussion in a motorcycle accident
B. A 76-year-old client chronic obstructive pulmonary disease and emphysema admitted 24 hours ago
C. A 40-year-old client with a new diagnosis of diabetes who will be discharged today
D. A 62-year-old client newly admitted with congestive heart failure exacerbation
B. A 76-year-old client chronic obstructive pulmonary disease and emphysema admitted 24 hours ago
