Prioritizing, Delegation, Patient care

Question 1

Prioritizing

Answer 1

• General rules
  
  • Acute beats chronic
  • Modifying phrase most important
  • Fresh post-op beats medical or other surgical
  • Stable beats unstable
    
    • Stable
      
      • use of the word stable
      • chronic illness
      • Post-op >12 hours
      • Local or regional anesthesia
      • Unchanged assessment
      • Phrase “to be discharged”
      • Category A or B Lab values
      • Expected s/s
    • Unstable
      
      • Use of the word unstable
      • Acute illness
      • Post-op <12 hours
      • General anesthesia
      • Changing assessment
      • Phrases “newly admitted” or “newly diagnosed” (within 12 hours)
      • Category C or D Lab values
      • Unexpected or atypical s/s
      • Patients that are always unstable
        
        • hemorrhage
        • Hypoglycemia
        • High Fever >105 (seizure risk
        • Pulselessness or breathlessness
  • Tiebreaker: The more vital the organ, the higher the priority (based on modifying phrase)
    
    • Most vital → least vital
      
      • brain → lungs → heart → liver → kidney → pancreas

Question 2

Delegation to LPN

Answer 2

• Do not delegate
  
  • Starting an IV
  • Hanging or mixing IV meds
  • Evaluating an IV site
  • Giving an IV push/piggyback meds
  • Giving a blood transfusion
  • Performing assessments that require inferences/judgments
    
    • admissions, discharge, transfer assessments, any change of status assessment
  • Plan of care
  • Developing or performing teaching (can reinforce and review)
  • Taking verbal orders from MD or transcribing orders
  • the first of any activity

Question 3

Delegation to a UAP

Answer 3

• Cannot chart but may document what they did
• Assessments (except for VS and accucheck)
• Meds and IVs - may apply OTC topical lotions and creams
• Treatments - enemas , cath (use as last option)
• Do not delegate safety to family

Question 4

Inappropriate behavior

Answer 4

• Intervention
  
  1. Tell the supervisor (if what they’re doing is illegal)
  2. Intervene immediately (if what they’re doing can harm a patient)
  3. Counsel them later on (if not harmful, just inappropriate)
  4. Ignore it. Just let it go (never used)

Question 5

Pre-interaction phase

Answer 5

• Purpose
  
  • for the nurse to explore his/her feelings
  • prevent judgmental, intolerant reactions
• Length
  
  • begins on report and ends when you meet the patient
• Correct answer
  
  • “the nurse will explore his/her feelings about”

Question 6

Introductory phase (orientation phase)

Answer 6

• Purpose
  
  • to establish relationship and assess
• Correct answers
  
  • nurse should be very tolerant, accepting, explorative, probing, “nosy”

Question 7

Working phase

Answer 7

• Purpose
  
  • to implement plan of care
• Correct answer
  
  • Should be focused, directive, “tough”
  • set limits
  • enforce proper communication