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Flashcards in Management/Priority/Delegation Deck (15):
1

A nurse is working with one licensed practical nurse (LPN) and a mental health tech (an unlicensed assistive personnel). Which newly admitted client would be appropriate to assign to the mental health tech?

A: An adolescent Dx w/dehydration & anorexia

B: A young adult who reports to be a heroine addict & states, "I am in W/D & seeing spiders."

C: A middle-aged pt Dx w/OCD

D: A 76 yo Dx w/severe depression

OCD pt.

The mental health tech (a type of unlicensed assistive personnel or UAP) can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has minimal risk of instability of condition and has a situation of expected outcomes.

2

The charge nurse is scheduled duties in the unit. Which of these clients should a charge nurse assign to a licensed practical nurse (LPN)?

A: A trauma pt w/multiple lacerations that require complex dressings

B: An older pt Dx w/cystitis & an indwelling urethral cath

C: A confused pt whose family CO the NSG care 2 days after pt's surgery

D: A pt admitted w/a Dx of possible transient ischemic attack w/unstable neurological signs

B: An older pt Dx with cystitis

This is the most stable client who has more chance of predictable outcomes and minimal risk for complications. The other clients require more complex care and would need the attention of the RN.

3

Two members of the interdisciplinary team are arguing about the plan of care for a client. Which action could any one of the members of the team use as a de-escalation strategy?

A: Bring the communication focus back to the pt

B: Interrupt, apologize for the interruption, and change the subject

C: Tell the violators that they must remain calm and be reasonable

D: Adjourn the meeting & reschedule when everyone has calmed down

A: Bring the focus back to the pt

Bringing the subject of the communication back to the client refocuses attention on the client's care, instead of the manner of communication. It is the most effective strategy because it is an example of collaboration. The other options are non-productive and may even make matters worse.

4

Following an alert of an internal disaster and the need for beds, the charge nurse is asked to list the clients who are potential discharges within the next hour. Which one of these clients should the charge nurse select?

A: A middle-aged client who was admitted yesterday with an internal automatic defibrillator and complaints of “passing out at unknown times”

B: An older adult client who has been diagnosed with type 2 diabetes mellitus for more than 20 years, admitted with diabetic ketoacidosis 24 hours ago

C: An adolescent admitted the prior night with Tylenol intoxication

D: A school-aged child who was admitted at the change of shifts with a diagnosis of suspected bacterial meningitis

B: DM type 2 Pt w/DKA

This client is the most stable and has a chronic condition. Tylenol intoxication requires at least three to four days of intensive observation for the risk of hepatic failure. The other clients should be considered unstable.

5

At the beginning of the shift, the nurse is reviewing the status of each of the assigned clients in the labor and delivery unit. Which of these clients should the nurse check first?

A: An adolescent who is 18-weeks pregnant with a report of no fetal heart tones and is coughing up frothy sputum

B: A young woman who is a grand multipara, cervical dilation to 4 cm and is 50% effaced

C: A middle-aged woman with a history of two prior vaginal term births and who is 2 cm dilated

D: A young woman, first-time para, cervical dilation to 1 cm and contractions 15 minutes apart

A: An adolescent who is 18-weeks pregnant with a report of no fetal heart tones and is coughing up frothy sputum

The 18 year-old client has an actual complication of left-sided heart failure and a possible stillborn birth.

6

The charge nurse has a health care team that consists of one practical nurse (PN), one unlicensed assistive personnel (UAP) and one PN nursing student. The charge nurse has made these assignments. Which assignment should be questioned by the nurse manager?

A: The admission at the change of shifts of a client diagnosed with atrial fibrillation and acute heart failure - PN

B: An older adult client who had been diagnosed with a myocardial infarction one week ago - UAP

C: A child diagnosed with second-degree burns over 30% of the body and has IV packed red cells running and an order for albumin IV - charge nurse

D: A client who was diagnosed with a major stroke six days ago - PN nursing student

A: The admission at the change of shifts of a client diagnosed with atrial fibrillation and acute heart failure - PN


The care for a new admission with risk of instability should be performed by an RN. In addition, because the client was admitted at the change of shifts, the stability of the client would not have been established. The charge nurse should take this client. PNs should be delegated clients who are stable with minimal risk for instability; medication administration, except for IV push; sterile procedures; reinforcement of teaching and other client care that does not require judgments and decisions. The nurse may delegate routine tasks and a stable client to UAPs.

7

A newly admitted 78 year-old client is diagnosed with severe dehydration. When planning care for this client, the nurse should assign which task to an unlicensed assistive personnel (UAP)?

A: Report hourly outputs of less than 30 mL/hr within 15 minutes of the check

B: Converse with the client to determine if the mucous membranes are impaired

C: Check skin turgor every four hours along with the need to change the adult diaper

D: Monitor client's ability for movement in the bed from side to side

A: Report hourly outputs of less than 30 mL/hr within 15 minutes of the check

When assigning a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported and when. Because the RN is responsible for all care-related decisions, only routine tasks should be assigned to UAPs because such tasks do not require judgments and decisions.

8

The nurse is caring for a client diagnosed with anemia and confusion. Which task could the nurse delegate to the unlicensed assistive personnel (UAP)?

A: Report mental status changes & level of mental clarity

B: Test stool for occult blood & urine for pH w/a report of the results

C: Assess and document skin turgor & skin color changes

D: Suggest foods that are high in iron and prepare a lists of likes and dislikes

B: Test stool for occult blood & urine for pH w/a report of the results

The UAP can perform routine tasks that have known or expected outcomes. These tasks typically do not require nursing judgment or decision-making.

9

The nurse is assigned to a client newly diagnosed with active tuberculosis (TB) and a productive cough. Which of these interventions would be a priority for the nurse to implement?

A: Place client in a private room and implement droplet precautions

B: Reinforce that everyone should wash their hands before and after entering the room

C: Have the client cough into a tissue and dispose of the tissue in a separate bag

D: Place the client in a negative pressure private room and have disposable particulate respirators available for hospital employees

D: Place the client in a negative pressure private room and have disposable particulate respirators available for hospital employees

A client with active tuberculosis should be hospitalized in a negative pressure room to prevent cross contamination of the disease. The client would be placed on airborne precautions because this bacteria can be suspended in the air for long periods of time and may be carried for long distances on air currents. Any hospital employee entering the room would need to wear a disposable micron mask or disposable particulate respirator (N-95, for example). The Centers for Disease Control and Prevention (CDC) state that visitors can wear surgical masks.

10

A client asks the nurse to call the police and states: “I need to report that I am being abused by a nurse.” The nurse should take which action?

A: Obtain more details of the client’s claim of abuse by a nurse

B: Assist with the report of the client’s complaint to the police

C: Document the statement on the client’s chart with a report to the manager

D: Focus on reality orientation to time, place and person

A: Obtain more details of the client’s claim of abuse by a nurse


The advocacy role of the professional nurse, as well as the legal duty of the reasonable prudent nurse, requires the investigation of claims of abuse or violation of rights. The nurse is legally accountable for actions delegated to others. The application of the nursing process requires that the nurse gather more information, assessment before interventions and before documenting or reporting the complaint.

11

The nurse receives a report on a client being admitted with the diagnosis of cirrhosis of the liver and ascites. What should the nurse emphasize to the nursing assistant about providing care for this client?

A: The client may ambulate and sit in a chair as tolerated

B: The client is to ambulate as tolerated and be positioned in semi-Fowler's position when in bed

C: The client should remain on bed rest in a semi-Fowler's position

D: The client should ambulate as tolerated, resting in bed with legs elevated between walks

D: Ambulate as tol, & elevate legs

Encourage alternating periods of ambulation and bed rest with legs elevated to mobilize edema and ascites. Encourage and assist the client to gradually increase the duration and frequency of walks.

12

Don't delegate to a reassigned nurse if you see clues like:

Newly diagnosed, after a TIA, newly admitted, severe dehydration and the like

13

A novice charge nurse is delegating duties. Which tasks, if delegated to an unlicensed assistive personnel (UAP), would require intervention by the nurse manager?

To empty a urethral collection bag

To feed a 2 year-old with a broken arm

To help an older adult client to the bathroom

To bathe a woman with internal radon seeds and device

To bathe a woman with internal radon seeds and device

A client with internal radiation is complex care and is not suitable to be assigned to a UAP. Additionally, the client would not receive a complete bath because movement is minimized during this therapy to prevent the slippage of the device.

14

A client is transported by a family member to the emergency department following a boating accident. The client is conscious, shivering, and confused. The client is still wearing wet clothes. Which interventions does the nurse implement? (Select all that apply.)

A: Monitor vital signs
B: Remove wet clothes
C: Massage cold extremities
D: Infuse warm IV solutions as ordered
E: Apply warm blankets
F: Give sips of warm fluids

A, B, D, E

This client is at risk for hypothermia. In a conscious client, wet clothing should be removed carefully. External rewarming, using blankets or heat packs placed under the arms and on the neck, chest, and groin, is appropriate. In-hospital treatment also includes monitoring core temperature and cardiac rhythm, ventilating with warm humidified air/oxygen to help stabilize core temperature and administering warm IV fluids. Sips of warm fluids may be given to the conscious and alert client only after his condition is stabilized. Extremities should never be massaged.

15

The nurse receives report on the following client assignments. Which client should the nurse assess first?

A: A client diagnosed with gastroesophageal reflux disease (GERD) reporting difficulty swallowing

B: A client diagnosed with peptic ulcer disease (PUD) who reports feeling dizzy

C: A client who underwent a partial gastrectomy and reports feeling lightheaded

D: A client reporting severe gastric distress after taking ibuprofen

B: A client diagnosed with peptic ulcer disease (PUD) who reports feeling dizzy

Dizziness with PUD may indicate hemorrhaging. The findings in the other options are either expected and are not life-threatening: clients may feel lightheaded when they are not drinking enough fluids after a gastrectomy; difficulty swallowing can be a symptom of GERD; gastrointestinal symptoms are the most common side effects of NSAIDs.