7. PN is assigned the following clients. Which client should PN assess first?
1. The client who is 4 days postoperative abdominal surgery and is complaining of abdominal pain when ambulating.
2. The client who 1 day postoperative femoral-popliteal repair has a 3+ posterior tibial pulse.
3. The client who had an abdominal aortic repair who had a urine output of 150 mL in the last 8 hours.
4. The client with deep vein thrombosis who is complaining about being unable to get out of the bed.
8. PN is caring for a client receiving heparin sodium via constant infusion. The heparin protocol reads to decrease the IV rate by 100 units/hour if the PTT is between 78 to 90 seconds. The current PTT level is 85 seconds. The heparin comes in 500 mL of D5W with 25,000 units of heparin added. The current rate on the IV pump is 18 mL per hour. At what rate should the nurse set the pump?
9. The unlicensed assistive personnel (UAP) is caring for the client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention by PN?
1. The UAP is elevating the client’s legs on two pillows.
2. The UAP is massaging the client’s calf muscles.
3. The UAP is instructing the client to stay in the bed.
4. The UAP is calculating the client’s shift intake and output.
10. An 80-year-old client is being discharged home after having surgery to débride a chronic venous ulcer on the right ankle. Which referral is most appropriate for DH, the charge nurse, to make?
1. Hospice.
2. Home health.
3. Physical therapist.
4. Cardiac rehabilitation.
CLINICAL SCENARIO
56 PRIORITIZATION, DELEGATION, ANDMANAGEMENT OFCARE FOR THENCLEX-RN®EXAM
The correct answer number and rationale for why it is the correct answer are given in boldface type.
Rationales for why the other possible answer options are incorrect also are given, but they are not in bold-face type.
1. 1. Intermittent claudication is a symptom of arterial occlusive disease; therefore, this client does not need to be assessed first.
2. The client with calf pain could be experi-encing deep vein thrombosis (DVT), a complication of immobility, which may be fatal if a pulmonary embolus occurs; there-fore, this client should be assessed first.
3. The client experiencing low back pain when sitting in a chair should be assessed but not prior to the client with suspected DVT.
4. The nurse should address the client’s concern about the food, but it is not priority over a physiological problem.
Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Analysis
MAKING NURSING DECISIONS:When deciding which client to assess first, the test taker should determine whether the signs/symptoms the client is exhibiting are normal or expected for the client situation. After eliminating the ex-pected options, the test taker should determine which situation is more life threatening.
2. 1. Therapeutic levels for PTT should be 11/2 to 2 times the normal value, which is 39 seconds; therefore, this client is at risk for bleeding. The prolonged PTT indi-cates the client is receiving heparin (drug of choice to treat DVT). The nurse should stop the infusion and follow the facility protocol.
2. The hemoglobin is within normal range and the client with Raynaud’s disease does not have a problem with bleeding.
3. The WBC count is elevated (normal is 5,000 to 10,000), but it would be elevated in a client who has an infection such as venous stasis ulcer.
4. The nurse should notify the HCP on rounds of any laboratory data that are abnormal but not immediately life threatening. The triglyc-eride level is high, but it will take weeks to
months of a heart healthy diet, exercise, and possibly medications to lower this level.
Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing: Implementation: Client Needs – Safe and Effec-tive Care Environment: Safety and Infection Control:
Cognitive Level – Synthesis
MAKING NURSING DECISIONS:When a question asks for immediate intervention, the test taker must decide whether there is an intervention the nurse can implement immediately or whether the HCP must be notified. If the data are abnormal—but not life threatening—then the option can be eliminated as a possible correct answer.
3. 1. The nurse should first assess the client to de-termine the status prior to notifying the HCP.
2. The unlisted assistive personnel (UAP) has notified the nurse of a potentially serious situation. The nurse must first assess the client prior to taking any action.
3 The nurse might place the client in Trende-lenburg position once cardiovascular shock is determined.
4. The nurse should immediately go to the client’s room to assess the client.
Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Analysis
MAKING NURSING DECISIONS:Any time the nurse receives information about a client (who may be experiencing a complication) from an-other staff member, the nurse must assess the client. The nurse should not make decisions about the client’s needs based on another staff member’s information.
4. 1. Because laboratory values called into a unit usually include critical values, the charge nurse should tell the unit secretary “to show me any lab information that is called in immediately.” The charge nurse must evaluate this information immediately.
2. Posting laboratory results is the responsibility of the laboratory staff, not the nursing staff.
3. This is unrealistic because laboratory data are important information that must be called in to a unit when there is a critical value so that immediate action can be taken for the client’s
ANSWERS AND RATIONALES
welfare. The secretary must know how to process the information.
4. The unit secretary should verify the informa-tion by repeating back the informainforma-tion at the time of the call, not by making a second tele-phone call to the lab.
Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care:
Cognitive Level – Synthesis
MAKING NURSING DECISIONS:The test taker must be knowledgeable of the roles of all mem-bers of the multidisciplinary healthcare team, as well as HIPAA rules and regulations. The nurse must ensure the healthcare team member knows appropriate actions to take in specific situations.
These will be tested on the NCLEX-RN®.
5. 1. Vitamin K is the antidote for warfarin (Coumadin) overdose and is administered to a client when his or her INR level is above the therapeutic 2–3; therefore, the nurse should question administering this medication.
2. Inderal is administered to clients diagnosed with hypertension; therefore, the nurse would not question administering this medication.
3. Procardia reduces the number of vasospastic attacks in clients with Raynaud’s disease;
therefore, the nurse should question adminis-tering this medication to a client with hypotension.
4. Vasotec, an ACE inhibitor, is administered to clients with diabetes to help prevent diabetic nephropathy. The nurse would not question administering this medication.
Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Safe and Effective Care Environment: Safety and Infection Control:
Cognitive Level – Analysis
MAKING NURSING DECISIONS:The nurse must be aware of interventions that must be imple-mented prior to administering medications. The nurse must know what to monitor prior to ad-ministering medications because untoward reac-tions and possibly death can occur.
6. 1. This client is exhibiting signs/symptoms of a potentially fatal complication of DVT—
pulmonary embolism. The nurse should assess this client first.
2. Intermittent claudication of the feet, hands, and arms is a symptom of Buerger’s disease; there-fore, this client should not be assessed first.
3. The client with an aortic aneurysm is expected to have an audible bruit and does not indicate any life-threatening condition; therefore, this client does not need to be assessed first.
4. The client with acute arterial ischemia should have unpalpable pedal pulses to be considered a medical emergency; therefore, this client does not need to be assessed first.
Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Analysis
MAKING NURSING DECISIONS:The test taker must determine which sign/symptom is not expected for the disease process. If the sign/
symptom is not expected, then the nurse should assess the client first. This type of question is determining if the nurse is knowledgeable of the signs/symptoms of a variety of disease processes.
7. 1. Because the client has been on the daily aspirin for more than a year, the nurse should assess for bleeding by asking ques-tions such as, “Do your gums bleed after brushing teeth?” or “Do you notice blood when you blow your nose?”
2. Because aspirin can cause gastric distress, the nurse could instruct the client to stop taking it;
however, because this is a daily medication being used as an antiplatelet agent, the nurse should provide information that would allow the client to continue the medication.
3. The nurse should realize the stomach discom-fort is probably secondary to daily aspirin, and enteric-coated aspirin would be helpful to de-crease the stomach discomfort and allow the client to stay on the medication, but the nurse should first assess the client for bleeding.
4. Because aspirin is not a prescription medica-tion, the nurse can recommend a different form of aspirin, such as one that is enteric coated. However, if the enteric-coated aspirin does not relieve the pain, the HCP should then be notified.
Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Analysis
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.
ANSWERS
58 PRIORITIZATION, DELEGATION, ANDMANAGEMENT OFCARE FOR THENCLEX-RN®EXAM
8. 1. This statement indicates the new graduate needs more teaching because the nurse is responsible for delegating the right task to the right individual. Absolutely no one works on the nurse’s license but the nurse holding the license.
2. The nurse does retain accountability for the task delegated; therefore, the new graduate does not need more teaching.
3. The nurse must make sure the unlicensed as-sistive personnel (UAP) is able to perform the task safely and competently; therefore, the new graduate does not need more teaching.
4. The nurse must make sure the delegated task was completed correctly; therefore, the new graduate does not need more teaching.
Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care:
Cognitive Level – Synthesis
MAKING NURSING DECISIONS:An RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to a UAP.
Tasks that cannot be delegated are nursing interventions requiring nursing judgment. The nurse must be aware of delegation rules and regulations.
9.1. The manufacturer of a product would provide biased information and would not provide the best data to support a change proposal.
2. Research studies with a limited number of participants indicate the need for further re-search and would not be the best rere-search to support a change proposal.
3. Research should provide clear statistical data that support the research problem or hypothesis.
4. The more research articles there are that support a change proposal, the more valid is the information, which increases the possibility for change to be considered by the healthcare facility.
Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Evaluation: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Knowledge
MAKING NURSING DECISIONS:The NCLEX-RN® blueprint includes nursing care based on evidence-based practice. The nurse must be knowledgeable of nursing research.
10. 1. The unlicensed assistive personnel (UAP) can clean the perineal area of a client who
is on bed rest and who has an indwelling catheter. Because the client is stable, this nursing task could be delegated to the UAP.
2. The UAP can obtain the client’s intake and output, but the nurse must evaluate the data to determine whether interventions are needed or whether interventions are effective.
3. A client who is third-spacing is unstable and in a life-threatening situation; therefore, the nurse cannot delegate the UAP to give this client a bath.
4. This is a medication enema, and the UAP cannot administer medications. In addition, if a cation-exchange resin enema is ordered, the client is unstable and has excessively high serum potassium (K+) level.
Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care:
Cognitive Level – Synthesis
MAKING NURSING DECISIONS:An RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to a UAP.
Tasks that cannot be delegated are nursing interventions requiring nursing judgment.
11. 1. Although the nurse could request another unlicensed assistive personnel (UAP) to per-form the task, this is not the best action be-cause the nurse should demonstrate applying SCDs so that the UAP can learn how to complete the task.
2. This is the priority action because the nurse will ensure the UAP knows how to apply SCDs correctly, thereby enabling the nurse to delegate the task to the UAP successfully in the future.
3. The nurse could do the task, but if the UAP is not shown how to do it, then the UAP will not be able to perform the task the next time it is delegated.
4. The UAP could watch a video demonstrating this task, but the priority action is that the nurse should demonstrate SCD application to the UAP.
Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Safety and Infection Control: Cognitive Level – Application
MAKING NURSING DECISIONS:The nurse cannot delegate any task in which the UAP admits to not being able to perform. It is the nurse’s re-sponsibility to know what can be delegated and
when. The nurse may have to complete the task if the UAP is not competent to do so.
12.1. The nurse should not assign assessment of a client to an LPN even if the client is stable.
2. The LPN cannot initiate administration of blood; therefore, this task must be completed by the nurse.
3. The LPN can administer medications;
therefore, the LPN could hang a bag of heparin on an IV pump to this client.
4. The nurse must assess for dysrhythmias dur-ing the insertion, and the nurse assistdur-ing the HCP should be experienced in inserting the line. An LPN pulled from another unit should not be assigned this task.
Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care:
Cognitive Level – Synthesis
MAKING NURSING DECISIONS:The nurse cannot assign assessment, teaching, evaluation, or an unstable client to a LPN. The LPN can tran-scribe HCP orders and can call HCPs on the phone to obtain orders for a client.
13.1. The client is having signs/symptoms of a blood transfusion reaction. The nurse must stop the transfusion immediately and then assess the client’s vital signs.
2. The HCP needs to be notified, but not be-fore the nurse stops the blood transfusion.
3. The nurse should maintain a patent IV so that medications can be administered, but this is not the first intervention.
4. Any time the nurse suspects the client is having a reaction to blood or blood prod-ucts, the nurse should stop the infusion at the spot closest to the client and not allow any more of the blood to enter the client’s body. This is the nurse’s first intervention.
Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Physiological Integrity: Reduction of Risk Potential:
Cognitive Level – Application
MAKING NURSING DECISIONS:The nurse should remember: If a client is in distress and the nurse can do something to relieve the distress, it should be done first, before assessment. The test taker should select an option that directly helps the client’s condition.
14.1. A research article should answer the question
“why”: Why was the research done? This
statement indicates the charge nurse under-stands how to read a research article.
2. The cost of the research is not pertinent when reading a research article and de-termining whether the research supports evidence-based practice. This statement indicates the charge nurse does not un-derstand how to read a research article.
3. A research article should answer the question “what”: What research method was used? This statement indicates the charge nurse understands how to read a research article.
4. A research article should answer the question “where”: In what setting was the research conducted? This statement indi-cates the charge nurse understands how to read a research article.
Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Evaluation: Client Needs – Safe and Effective Care Environment: Management of Care:
Cognitive Level – Application
MAKING NURSING DECISIONS:The NCLEX-RN® blueprint includes nursing care based on
evidence-based practice. The nurse must be knowledgeable of nursing research.
15.1. The nurse should write the order on the HCP’s order and write “per telephone order (TO),” but this is not the nurse’s first intervention.
2. The nurse does not need to have another nurse verify the HCP’s telephone order.
3. The Joint Commission has implemented this requirement for all telephone orders.
The nurse should document on the HCP’s order “repeat order verified.”
4. The nurse should transcribe the order to the MAR, but it is not the first intervention.
Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Management of Care:
Cognitive Level – Knowledge
MAKING NURSING DECISIONS:The NCLEX-RN® blueprint includes nursing care that is ruled by legal requirements as well as rules and regulations of the Joint Commission, Centers for Medicare &
Medicaid Services, Centers for Disease Control and Prevention, and the Occupational Safety and Health Administration. The nurse must be knowledgeable of these standards.
16.1. The therapeutic level for a client on warfarin (Coumadin) is an INR of 2 to 3; therefore, this client does not warrant intervention.
ANSWERS
60 PRIORITIZATION, DELEGATION, ANDMANAGEMENT OFCARE FOR THENCLEX-RN®EXAM
2. These hemoglobin/hematocrit levels are a little low but not so critical that this would warrant intervention by the charge nurse.
3. A platelet count of less than 100,000 per milliliter of blood indicates thrombocy-topenia; therefore, this client warrants intervention by the charge nurse.
4. This is a normal red blood cell count; there-fore, the charge nurse would not need to
4. This is a normal red blood cell count; there-fore, the charge nurse would not need to