Prioritization Delegation And Management Of Care

16 Answer is 2. 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 MAKING NURSING DECISIONS: There will be management questions on the NCLEX-RN®. In many instances, there is no test-taking strategy; the nurse must be knowledgeable of management issues 17 Answer is 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. MAKING NURSING DECISIONS: The test taker should ask “is the assessment data normal for” the disease process. If it is normal for the disease process, the nurse would not need to intervene; if it is not normal for the disease process, then this warrants intervention by the nurse. 18 Answer is 2. Assessing the client’s intake will help the nurse to determine the extent of the client’s complaints. This is the first intervention. MAKING NURSING DECISIONS: Assessment is the first step of the nursing process, and the test taker should use the nursing process or some other systematic process to assist in determining priorities. 19 Answer is 3. A client with fulminant pulmonary edema is experiencing an acute, life-threatening problem. The most experienced nurse should be assigned to this client MAKING NURSING DECISIONS: The test taker must determine which client is the most unstable and would require the most experienced nurse, thus making this type of question an “except” question. Three clients are either stable or have non–life-threatening conditions. 20 Answer is 1. The client’s International Normalized Ratio (INR) is 3.4. The therapeutic range is 2 to 3 for a client diagnosed with atrial fibrillation. This client is at risk for bleeding. The nurse should hold the medication and discuss the warfarin with the HCP. MAKING NURSING DECISIONS: This is an alternate type question included in the NCLEX-RN® blueprint. The test taker must be able to read a medication administration record (MAR), be knowledgeable of medications, and be able to make an appropriate decisions as to the nurse’s most appropriate intervention 21 Answer is 3. 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 determined, the nurse should not delegate any client care MAKING NURSING DECISIONS: This is an “except” question. The test taker could ask which task is appropriate to delegate to the UAP; three options would be appropriate to delegate and one would not be. Remember the RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to the UAP. 22 Answer is 1. 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. MAKING NURSING DECISIONS: The NCLEX-RN® blueprint includes nursing care that is ruled by legal requirements. The nurse must be knowledgeable of these issues. 23 Answer is 1. 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. 24 Answer is 1. The LPN can contact the HCP and give pertinent information. The INR is high (therapeutic is 2 to 3), and the HCP should be informed MAKING NURSING DECISIONS: The nurse cannot assign assessment, teaching, evaluation, or an unstable client to an LPN. The LPN can transcribe HCP orders and can call them on the phone to obtain orders for a client. 25 Answer is 2. Unlicensed assistive personnel (UAP) have the ability to keep the victims calm; therefore, this is an appropriate action. This action is not critical to the safety of the victims. MAKING NURSING DECISIONS: The test taker must be knowledgeable of the role of each member of the multidisciplinary healthcare team as well as HIPAA rules and regulations. These topics will be tested on the NCLEX-RN® exam 26 Answer is 3. 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. MAKING NURSING DECISIONS: In any business, including a healthcare facility, arguments or discussions of confidential information should not occur among staff of any level where the customers—in this case, the clinic clients—can hear it or see it. 27 1, 2, 3, and 5 are correct. 1. Case managers help coordinate healthcare 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 outpatient 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. MAKING NURSING DECISIONS: The test taker must be knowledgeable of the role of each member of the multidisciplinary healthcare team as well as HIPAA rules and regulations. These topics will be tested on the NCLEX-RN® exam. This is an alternate type question wherein the test taker must select more than one option as correct and must select all appropriate options to receive credit for a correct answer 28 Answer is 4. Grapefruit juice can cause calcium channel blockers to rise to toxic levels. Grapefruit juice inhibits cytochrome P450-3A4 found in the liver and intestinal wall. This statement warrants intervention by the nurse MAKING NURSING DECISIONS: The test taker must be knowledgeable of medications. In most scenarios, there is no test-taking hint to help the test taker when answering medication questions except common nursing interventions, such as do not administer cardiac medications if client has AP 29 Answer is 3. 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. MAKING NURSING DECISIONS: There will be management questions on the NCLEX-RN®. In many instances, there is no test-taking strategy; the nurse mu 30 Answer is 3. 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 behavior MAKING NURSING DECISIONS: The NCLEX-RN® blueprint includes nursing care that is ruled by legal requirements. The nurse must be knowledgeable of management issues. 16. The charge nurse on the cardiac unit is counseling a female staff nurse because the nurse has clocked in late multiple times for the 7:00 a.m. to 7:00 p.m. shift. Which conflict resolution uses the win-win strategy? 1. The charge nurse terminates the staff nurse as per the hospital policy so that a new nurse can be transferred to the unit. 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. 3. The charge nurse puts the staff nurse on probation with the understanding that the next time the staff nurse is late to work she will be terminated. 4. The staff nurse asks another staff member to talk to the charge nurse to explain that she is a valuable part of the team. 17. Which client warrants immediate intervention by the nurse? 1. The client diagnosed with pericarditis who has chest pain with inspiration. 2. The client diagnosed with mitral valve regurgitation who has thready peripheral pulse. 3. The client diagnosed with Marfan syndrome who has pectus excavatum. 4. The client diagnosed with atherosclerosis who has slurred speech and drooling. 18. The UAP working in a long-term care facility notifies the nurse that the client diagnosed with congestive heart failure who is on a low-sodium diet is complaining that the food is inedible. Which intervention should the nurse implement first? 1. Have the family bring food from home for the client. 2. Check to see what the client has eaten in the past 24 hours. 3. Tell the client that a low-sodium diet is an important part of the diagnosis. 4. Ask the dietician to discuss food preferences with the client. 19. The charge nurse on the cardiac unit is making shift assignments. Which client should be assigned to the most experienced nurse? 1. The client diagnosed with mitral valve stenosis. 2. The client diagnosed with asymptomatic sinus bradycardia. 3. The client diagnosed with fulminant pulmonary edema. 4. The client diagnosed with acute atrial fibrillation. 20. The evening nurse in a long-term care facility is preparing to administer medications to a client diagnosed with atrial fibrillation. Which medication should the nurse question administering? 1. Warfarin (Coumadin), an anticoagulant. 2. Metoclopramide (Reglan), a gastric motility medication. 3. Docusate (Colace), a stool softener. 4. Atorvastatin (Lipitor), an antihyperlipidemic. 21. The nurse and the UAP enter the client’s room and discover that the client is unresponsive. Which action, according to the American Heart Association (AHA) guidelines, should the nurse assign to the UAP first? 1. Ask the UAP to check whether the client is asleep. 2. Tell the UAP to perform cardiac compressions. 3. Instruct the UAP to get the crash cart. 4. Request the UAP to put the client in a recumbent position 22. The elderly client on a cardiac unit has a do not resuscitate (DNR) order written. Which intervention should the nurse implement? 1. Continue to care for the client’s needs as usual. 2. Place notification of the DNR inside the client’s chart. 3. Refer the client to a hospice organization. 4. Limit visitors to two at a time, so as not to tire the client. 23. The nurse is initiating discharge teaching to a 68-year-old male client who had quadruple coronary bypass surgery. Which priority question should the nurse ask the client? 1. “Are you sexually active?” 2. “Can you still drive your car?” 3. “Do you have pain medications at home?” 4. “Do you know when to call your HCP?” 24. The LPN informs the clinic nurse that the client diagnosed with atrial fibrillation has an INR of 4.5. Which intervention should the nurse implement? 1. Tell the LPN to notify the clinic healthcare provider (HCP). 2. Instruct the LPN to assess the client for abnormal bleeding. 3. Obtain a stat electrocardiogram on the client. 4. Take no action because this INR is within the normal range. 25. The nurse at a disaster site is triaging victims when a woman states, “I am a certified nurse aide. Can I do anything to help?” Which action should the nurse implement? 1. Request the woman to please leave the area. 2. Ask the woman to check the injured clients. 3. Tell the woman to try and keep the victims calm. 4. Instruct the woman to help the paramedics. 26. The cardiac clinic nurse hears the UAP tell the client, “You have gained over 15 pounds since your last visit.” The scale is located in the office area. Which action should the clinic nurse implement? 1. Tell the UAP in front of the client to not comment on the weight. 2. Ask the UAP to put the client in the room and take no action. 3. Explain to the UAP, in private, that this is an inappropriate comment and violates HIPAA. 4. Report the UAP to the director of nurses of the clinic 27. The nurse on the cardiac unit is discussing case management with a client who asks, “Why do I need a case manager for my heart disease?” Which statements are most appropriate for the nurse to respond? Select all that apply. 1. “Case management helps contain the costs of your healthcare.” 2. “It will help enhance your quality of life with a chronic illness.” 3. “It decreases the fragmentation of care across many healthcare settings.” 4. “Case management is a form of health insurance for clients with chronic illnesses.” 5. “We try to provide quality care along the healthcare continuum.” 28. The client diagnosed with arterial hypertension and has been taking a calcium channel blocker, a loop diuretic, and an ACE inhibitor for 3 years. Which statement by the client would warrant intervention by the nurse? 1. “I have to go to the bathroom a lot during the morning.” 2. “I get up very slowly when I have been sitting for a while.” 3. “I do not salt my food when I am cooking it but I add it at the table.” 4. “I drink grapefruit juice every morning with my breakfast.” 29. The director of nurses in the cardiac clinic is counseling an unlicensed assistive personnel (UAP) in the clinic who returned late from her lunch break seven times in the past 2 weeks. Which conflict resolution uses the win-lose strategy? 1. The UAP explains she is checking on her ill mother during lunch, and the nurse allows her to take a longer lunch break if she comes in early. 2. The director of nurses offers the UAP a transfer to the emergency weekend clinic so that she will be off during the week. 3. The director of nurses terminates the UAP, explaining that all staff must be on time so that the clinic runs smoothly. 4. The UAP is placed on 1-month probation, and any further occurrences will result in termination from this position. 30. The cardiac clinic nurse has told the female unlicensed assistive personnel (UAP) twice to change the sharps container in the examination room, but it has not been changed. Which action should the nurse implement first? 1. Tell the UAP to change it immediately. 2. Ask the UAP why the sharps container has not been changed. 3. Change the sharps container as per clinic policy. 4. Document the situation and place a copy of the documentation in the employee file