prioritization-delegation-and-assignment-practice-exercises-for-the-nclex-examination-4th-edition

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Recommended resourcesAlfaro-Lefevre R. Critical thinking, clinical reasoning, and clinical judgment: apractical approach. ed 6 St Louis: Saunders; 2017.Hansten R. The Master Coach Manual for the Relationship & Results OrientedHealthcare Program. Port Ludlow, Wash: Hansten Healthcare PLLC;2014.Hansten R. Relationship and results oriented healthcare planning andimplementation manual. Port Ludlow, Wash: Hansten Healthcare PLLC;2008.Hansten R., Jackson M. Clinical delegation skills: a handbook for professionalpractice. ed 4 Sudbury, Mass: Jones & Bartlett; 2009.Hansten R. Coach as chief correlator of tasks to results through delegationskill and teamwork development. Nurse Leader 12(4):69–73.Hansten Healthcare PLLC website, http://www.Hansten.com orhttp://www.RROHC.com. Check for new delegation/supervisionresources, online delegation, and assignment education modules athttp://learning.Hansten.com.National Council of State Boards of Nursing website,http://www.ncsbn.org. Contains links to state boards and abundantresources relating to delegation and supervision. Also download theANA and NCSBN Joint Statement on Delegation. The decision trees andstep-by-step process through the five rights are exceptionally clear anda great review to prepare for the NCLEX.42
PA R T 2Prioritization, Delegation, andAssignment in Common HealthScenarios43
Page 2 and 3: Prioritization, Delegation, andAssi
Page 4 and 5: Table of ContentsCover imageTitle p
Page 6 and 7: Chapter 10: Visual and Auditory Pro
Page 8 and 9: QuestionsAnswer KeyCase study 5: Di
Page 10 and 11: Answer KeyIllustration CreditsChapt
Page 12 and 13: Names: LaCharity, Linda A., author.
Page 14 and 15: Department of Nursing The Universit
Page 16 and 17: To faculty and other usersPatient c
Page 18 and 19: AcknowledgmentsWe would like to tha
Page 20 and 21: IntroductionRuth Hansten, PhD, MBA,
Page 22 and 23: not so apparent. Patients in all ca
Page 24 and 25: 2. The second level is immediately
Page 26 and 27: SupervisionWhenever a nurse delegat
Page 28 and 29: or evaluated activities of assistiv
Page 30 and 31: Delegation and assignment: the five
Page 32 and 33: leadership and direction would that
Page 34 and 35: for surgery and procedures and befo
Page 36 and 37: Errors can result in uncompensated
Page 38 and 39: Principles for implementation ofpri
Page 40 and 41: 2008;34(10):17-25.Kozlowski S., Ilg
Page 44 and 45: C H A P T E R 144
Page 46 and 47: Questions1. Which postoperative cli
Page 48 and 49: measures. What action should the ch
Page 50 and 51: 50
Page 52 and 53: 4. Seek family assistance in resolv
Page 54 and 55: 29. The nurse is caring for a clien
Page 56 and 57: provider.3. Withhold the pain medic
Page 58 and 59: unconfirmed.4. Ask the HCP to valid
Page 60 and 61: Activity level and function address
Page 62 and 63: who present with first-time onset o
Page 64 and 65: 30. Ans: 2, 5, 6 The client who is
Page 66 and 67: 42. Ans: 3 If the social worker can
Page 68 and 69: Cancer68
Page 70 and 71: night shift nurse?1. “How many ti
Page 72 and 73: 2. Nausea3. Paresthesia4. Anorexia1
Page 74 and 75: 24. For a patient with osteogenic s
Page 76 and 77: assisting patients in cessation of
Page 78 and 79: years, biennial or annual mammograp
Page 80 and 81: 9. Ans: 2, 3, 5, 6 Mouthwash should
Page 82 and 83: 23.oxygenation and perfusion. Pulse
Page 84 and 85: 29. Ans: 2 Hyponatremia is a concer
Page 86 and 87: Focus: Prioritization.86
Page 88 and 89: Immunologic Problems88
Page 90 and 91: of prednisone due3. A patient with
Page 92 and 93:
4. Newly graduated RN who needs exp
Page 94 and 95:
1. The patient is currently taking
Page 96 and 97:
Answer Key1. Ans: 1 Because antihis
Page 98 and 99:
to the unit would not have experien
Page 100 and 101:
are given with other medications. M
Page 102 and 103:
Fluid, Electrolyte, and Acid-BaseBa
Page 104 and 105:
6. The health care provider has wri
Page 106 and 107:
4. Serum magnesium level of 0.8 mEq
Page 108 and 109:
2. Potassium level3. Chloride level
Page 110 and 111:
Answer Key1. Ans: 3 An adult should
Page 112 and 113:
muscle weakness. Although the other
Page 114 and 115:
acidosis. Older adults may be takin
Page 116 and 117:
Safety and Infection Control116
Page 118 and 119:
4. Take off gown.5. Perform hand hy
Page 120 and 121:
2. Communicating with other departm
Page 122 and 123:
2. Appropriate antibiotics have bee
Page 124 and 125:
3. Labetalol 20 mg IV over a 2-min
Page 126 and 127:
airborne or contact precautions. Fo
Page 128 and 129:
hand hygiene readily available for
Page 130 and 131:
cholinergic crisis, a possible effe
Page 132 and 133:
Respiratory Problems132
Page 134 and 135:
3. Completing in-depth admission as
Page 136 and 137:
1. Avoid potential environmental as
Page 138 and 139:
1. Encourage the patient to eat foo
Page 140 and 141:
4. Observing whether the patient's
Page 142 and 143:
4. The student nurses uses a twirli
Page 144 and 145:
6. Ans: 1 When the oxygen flow rate
Page 146 and 147:
changed daily but may be reinforced
Page 148 and 149:
32. Ans: 4 Infections are always a
Page 150 and 151:
C H A P T E R 7150
Page 152 and 153:
Questions1. The clinic nurse is eva
Page 154 and 155:
apply.1. Referral to community prog
Page 156 and 157:
4. Persisting chest pain at a level
Page 158 and 159:
Which action will the nurse take fi
Page 160 and 161:
4. Assisting the client in cleaning
Page 162 and 163:
38. The clinic nurse obtains this i
Page 164 and 165:
Answer Key1. Ans: 1 Dark or tarry s
Page 166 and 167:
13. Ans: 2 Because combination angi
Page 168 and 169:
contractions in the setting of myoc
Page 170 and 171:
information are activities that can
Page 172 and 173:
Hematologic Problems172
Page 174 and 175:
6. The nurse is reviewing the compl
Page 176 and 177:
16. A patient with iron deficiency
Page 178 and 179:
4. Educating the patient about ways
Page 180 and 181:
Answer Key1. Ans: 2 Guidelines for
Page 182 and 183:
prescribed actions also should be i
Page 184 and 185:
infection when a patient has a low
Page 186 and 187:
Neurologic Problems186
Page 188 and 189:
1. Documenting the seizure2. Perfor
Page 190 and 191:
5. Developing the nursing plan of c
Page 192 and 193:
1. Position the client sitting up i
Page 194 and 195:
most appropriate for this client?1.
Page 196 and 197:
Answer Key1. Ans: 3 A change in lev
Page 198 and 199:
14. Ans: 1, 2, 4, 5 All of the stra
Page 200 and 201:
report feeling chilled, but warming
Page 202 and 203:
additional educational preparation
Page 204 and 205:
Visual and Auditory Problems204
Page 206 and 207:
3. Client who requests a home healt
Page 208 and 209:
2. Instill a mydriatic agent, such
Page 210 and 211:
24. The nurse is caring for several
Page 212 and 213:
3. Rest eyes as much as possible an
Page 214 and 215:
the eye. The man needs to have emer
Page 216 and 217:
to the client's report of roaring s
Page 218 and 219:
29. Ans: 1 Topical phenylephrine us
Page 220 and 221:
Musculoskeletal Problems220
Page 222 and 223:
2. Remove throw rugs and other obst
Page 224 and 225:
5. Check the neurovascular status o
Page 226 and 227:
instruct the UAP to respond?1. “Y
Page 228 and 229:
1. A2. B3. C4. D228
Page 230 and 231:
Focus: Assignment, Supervision; Tes
Page 232 and 233:
21. Ans: 1 Moving directly from a l
Page 234 and 235:
C H A P T E R 1 2234
Page 236 and 237:
Questions1. The charge nurse is rev
Page 238 and 239:
had fundoplication to reinforce the
Page 240 and 241:
The unit has several clients with h
Page 242 and 243:
31. The nurse is caring for a clien
Page 244 and 245:
nurse do first?1. Explain that the
Page 246 and 247:
Answer Key1. Ans: 4 Laxatives shoul
Page 248 and 249:
therapist should be contacted to se
Page 250 and 251:
displacement, and the correct posit
Page 252 and 253:
The client is likely to report pain
Page 254 and 255:
Diabetes Mellitus254
Page 256 and 257:
bath.”6. An LPN/LVN is assigned t
Page 258 and 259:
fruity odor to his breath. The char
Page 260 and 261:
hours.”2. “Test your urine for
Page 262 and 263:
262
Page 264 and 265:
Answer Key1. Ans: 1 The older patie
Page 266 and 267:
job includes calling and paging phy
Page 268 and 269:
abdomen) to prevent day-to-day chan
Page 270 and 271:
Other Endocrine Problems270
Page 272 and 273:
4. Teaching the patient about side
Page 274 and 275:
3. Potassium level4. White blood ce
Page 276 and 277:
3. Check vital signs every 2 hours.
Page 278 and 279:
1. Bilateral exophthalmos2. Large v
Page 280 and 281:
frequently have dependent edema. Fo
Page 282 and 283:
increased blood glucose level, decr
Page 284 and 285:
C H A P T E R 1 5284
Page 286 and 287:
Questions1. Which actions will the
Page 288 and 289:
a long-term care facility, which fi
Page 290 and 291:
back, and groin. Which question sho
Page 292 and 293:
3. The client has not eaten anythin
Page 294 and 295:
Answer Key1. Ans: 2, 3, 5, 6 Curren
Page 296 and 297:
appropriate, but therapy will chang
Page 298 and 299:
Prioritization.29. Ans: 2 Dairy pro
Page 300 and 301:
Renal and Urinary Problems300
Page 302 and 303:
should the nurse delegate to an exp
Page 304 and 305:
mouth.”3. “If necessary, your H
Page 306 and 307:
1. Incontinence-associated dermatit
Page 308 and 309:
3. Assist the patient with morning
Page 310 and 311:
the scope of practice of profession
Page 312 and 313:
23. Ans: 1 The underlying pathophys
Page 314 and 315:
check BP in the arm opposite to the
Page 316 and 317:
Reproductive Problems316
Page 318 and 319:
postanesthesia care unit. Which nur
Page 320 and 321:
2. Irrigate the retention catheter
Page 322 and 323:
4. Because nausea and vomiting may
Page 324 and 325:
4. Providing discharge instructions
Page 326 and 327:
6. Ans: 1 An LPN/LVN working in a p
Page 328 and 329:
anxiety needs further assessment ne
Page 330 and 331:
The other actions also require corr
Page 332 and 333:
C H A P T E R 1 8332
Page 334 and 335:
Questions1. A 30-year-old woman wit
Page 336 and 337:
4. Go up the chain of command and c
Page 338 and 339:
when desired.5. Ask the parents if
Page 340 and 341:
26. A 3-day-old breast-fed infant i
Page 342 and 343:
maternity patients, and breast feed
Page 344 and 345:
4. A patient with contractions ever
Page 346 and 347:
transmission of group B streptococc
Page 348 and 349:
Focus: Assignment.16. Ans: 3 Fundal
Page 350 and 351:
Measure of increasing the percentag
Page 352 and 353:
flu but does not go far enough in f
Page 354 and 355:
C H A P T E R 1 9354
Page 356 and 357:
Questions1. A 3-month-old infant ar
Page 358 and 359:
laboratory result would cause the n
Page 360 and 361:
leukemia. The patient's sibling has
Page 362 and 363:
1. A 2-year-old patient with a vent
Page 364 and 365:
3. Obtain a history for the type of
Page 366 and 367:
4. “This behavior may be associat
Page 368 and 369:
is 24% (0.24 volume fraction), and
Page 370 and 371:
Answer Key1. Ans: 1 The infant's be
Page 372 and 373:
Electroencephalography may be indic
Page 374 and 375:
diuretics. The other children shoul
Page 376 and 377:
36. Ans: 2 Passage of brown stool i
Page 378 and 379:
patients are in common waiting area
Page 380 and 381:
C H A P T E R 2 0380
Page 382 and 383:
Questions1. The nurse is caring for
Page 384 and 385:
4. “Storage position is unimporta
Page 386 and 387:
16. The RN team leader has assigned
Page 388 and 389:
4. Ethambutol26. A patient diagnose
Page 390 and 391:
__________ mL36. During a check-up
Page 392 and 393:
drug is taken too long before the m
Page 394 and 395:
depression to worsen. Decreased hea
Page 396 and 397:
blocker used to treat GERD and PUD,
Page 398 and 399:
Emergencies and Disasters398
Page 400 and 401:
vomiting_____, _____, _____, _____5
Page 402 and 403:
department (ED); however, this is t
Page 404 and 405:
2. Accompanying organ donor special
Page 406 and 407:
are the priority interventions for
Page 408 and 409:
2. A firefighter who is showing com
Page 410 and 411:
Test Taking Tip: Use knowledge of g
Page 412 and 413:
18. Ans: 3 The correct intervention
Page 414 and 415:
30. Ans: 4 At least one representat
Page 416 and 417:
42. Ans: 3 The nurse recognizes tha
Page 418 and 419:
Psychiatric-Mental Health Problems4
Page 420 and 421:
me about what you are feeling and w
Page 422 and 423:
concern?1. His heart rate is increa
Page 424 and 425:
2. Tell her to care for the patient
Page 426 and 427:
2. Restrain the patient's arms and
Page 428 and 429:
4. Gently suggest that the patient
Page 430 and 431:
very simple and direct instructions
Page 432 and 433:
17. Ans: 4 Although the patient is
Page 434 and 435:
ensuring that the patient is not ex
Page 436 and 437:
PA R T 3Prioritization, Delegation,
Page 438 and 439:
Chest Pressure, Indigestion, andNau
Page 440 and 441:
4. Ms. S's cardiac telemetry monito
Page 442 and 443:
hours and recording the vital sign
Page 444 and 445:
Answer Key1. Ans: 1, 2, 4, 5, 6 Ris
Page 446 and 447:
admission, is not a priority at thi
Page 448 and 449:
Dyspnea and Shortness of Breath448
Page 450 and 451:
2. Forward bent posture3. Respirato
Page 452 and 453:
2. Keep accurate records of intake
Page 454 and 455:
Answer Key1. Ans: 1, 2, 3, 5 Baseli
Page 456 and 457:
was productive. The changes in Mr.
Page 458 and 459:
C A S E S T U D Y 3458
Page 460 and 461:
QuestionsThe RN is the leader of a
Page 462 and 463:
9. The UAP is delegated the task of
Page 464 and 465:
1. Check bilateral pedal pulses eve
Page 466 and 467:
educational scope of the UAP. Focus
Page 468 and 469:
Page 470 and 471:
QuestionsMs. J is a 63-year-old wom
Page 472 and 473:
1. Assisting the patient to replace
Page 474 and 475:
19. What intervention is required a
Page 476 and 477:
high. Focus: Prioritization.7. Ans:
Page 478 and 479:
failure) are essential at this time
Page 480 and 481:
Diabetic Ketoacidosis480
Page 482 and 483:
2. Checking and reporting Mr. D's b
Page 484 and 485:
interested in knowing?1. Mental sta
Page 486 and 487:
19. Which member of the health care
Page 488 and 489:
Answer Key1. Ans: 1, 2, 4, 5, 6 The
Page 490 and 491:
range.11. Ans: 2 Her calculations a
Page 492 and 493:
Page 494 and 495:
QuestionsThe nurse who is working f
Page 496 and 497:
1. Discontinue the patient's oxygen
Page 498 and 499:
13. The nurse still has visits to m
Page 500 and 501:
Answer Key1. Ans: 1, 4, 5, 6 Ms. A'
Page 502 and 503:
12. Ans: 2 The focus in home health
Page 504 and 505:
Page 506 and 507:
QuestionsMr. M is a 32-year-old man
Page 508 and 509:
1. Set up an oxygen delivery system
Page 510 and 511:
5. Teach the client to perform self
Page 512 and 513:
scope of practice for a UAP. The nu
Page 514 and 515:
role performance, and self-concept.
Page 516 and 517:
Multiple Patients With Adrenal Glan
Page 518 and 519:
6. Fluid restrictions to maintain b
Page 520 and 521:
UAP is best for indicating fluid re
Page 522 and 523:
Answer Key1. Ans: 3 The patient's s
Page 524 and 525:
indicator of fluid retention. The b
Page 526 and 527:
Page 528 and 529:
QuestionsAn RN is the leader of a t
Page 530 and 531:
pending. Ms. H asks, “What should
Page 532 and 533:
16. The UAP asks, “Why can’t Ms
Page 534 and 535:
unsure about follow-up.5. The nursi
Page 536 and 537:
Answer Key1. Ans: 6 Mr. R has sever
Page 538 and 539:
mouth will decrease fecal mass and
Page 540 and 541:
26. Ans: 4 In this circumstance, th
Page 542 and 543:
C A S E S T U D Y 1 0542
Page 544 and 545:
QuestionsThe RN is the leader of a
Page 546 and 547:
6. The team leader is talking to Ms
Page 548 and 549:
4. “I know you are having pain. L
Page 550 and 551:
he is going to have pain. He's a dr
Page 552 and 553:
getting enough pain medication. He
Page 554 and 555:
Answer Key1. Ans: 6, 3, 2, 1, 5, 4
Page 556 and 557:
staff members should be watchful fo
Page 558 and 559:
25. Ans: 3 Mr. H may be experiencin
Page 560 and 561:
position if assessments of the skin
Page 562 and 563:
Multiple Clients With Cancer562
Page 564 and 565:
5. Noting the presence and complexi
Page 566 and 567:
11. The team leader is teaching the
Page 568 and 569:
demonstration of any aspect of colo
Page 570 and 571:
currently receiving high-flow oxyge
Page 572 and 573:
Answer Key1. Ans: 1, 2, 5, 6 When t
Page 574 and 575:
instilled through the catheter, and
Page 576 and 577:
30. Ans: 1 For Mr. U, the tension p
Page 578 and 579:
Gastrointestinal Bleeding578
Page 580 and 581:
3. Insert an NG tube and observe ga
Page 582 and 583:
2. HCP should be notified for possi
Page 584 and 585:
2. Call the HCP and politely state
Page 586 and 587:
insert the tube into the most paten
Page 588 and 589:
awareness of and avoidance of deali
Page 590 and 591:
C A S E S T U D Y 1 3590
Page 592 and 593:
QuestionsMs. A, a 20-year-old colle
Page 594 and 595:
Ms. A's ongoing care?1. RN from a t
Page 596 and 597:
2. Blood pressure3. O 2 saturation4
Page 598 and 599:
21. As the shift ends, the nurse is
Page 600 and 601:
also be appropriate, but a more dir
Page 602 and 603:
client. Next, the nurse discusses p
Page 604 and 605:
Septic Shock604
Page 606 and 607:
protocols. Which action should the
Page 608 and 609:
10. When assessing the norepinephri
Page 610 and 611:
3. Experienced ICU RN who has been
Page 612 and 613:
before the intubation attempt. To m
Page 614 and 615:
C A S E S T U D Y 1 5614
Page 616 and 617:
QuestionsThe nurse admits Ms. C, an
Page 618 and 619:
4. Assessing lung sounds10. Ms. C's
Page 620 and 621:
dyspnea. She has been receiving dig
Page 622 and 623:
7. Ans: 4 Morphine is used in pulmo
Page 624 and 625:
this client's assessment indicates
Page 626 and 627:
Multiple Patients With PeripheralVa
Page 628 and 629:
the student nurse to avoid?1. Auscu
Page 630 and 631:
13. At noon, the LPN/LVN goes to ca
Page 632 and 633:
6. Check daily international normal
Page 634 and 635:
Answer Key1. Ans: 2, 3, 5 Hypertens
Page 636 and 637:
Assignment, Supervision.11. Ans: 1
Page 638 and 639:
involves surgical revascularization
Page 640 and 641:
Respiratory Difficulty After Surger
Page 642 and 643:
nurse ask the laboratory to draw bl
Page 644 and 645:
9. The HCP assesses Mr. E and presc
Page 646 and 647:
5. Provide oral care several times
Page 648 and 649:
Answer Key1. Ans: 3 The marked decr
Page 650 and 651:
clients who are unconscious or para
Page 652 and 653:
is experiencing. Focus: Prioritizat
Page 654 and 655:
Long-Term Care654
Page 656 and 657:
3. Gently dry after each cleansing.
Page 658 and 659:
2. Administer diphenoxylate 5 mg PO
Page 660 and 661:
Answer Key1. Ans: 2 IAD describes t
Page 662 and 663:
of UAP. In some states, long-term c
Page 664 and 665:
C A S E S T U D Y 1 9664
Page 666 and 667:
QuestionsThe charge nurse is workin
Page 668 and 669:
3. Crackles auscultated on inspirat
Page 670 and 671:
history.4. Perform blood glucose te
Page 672 and 673:
2. A sign of bronchial remodeling3.
Page 674 and 675:
and drained 120 mL over 12 hours. H
Page 676 and 677:
asthma attack. The mother's frustra
Page 678 and 679:
mother should be notified and advis
Page 680 and 681:
Total parenteral nutrition is not s
Page 682 and 683:
C A S E S T U D Y 2 0682
Page 684 and 685:
QuestionsNote: In this case study,
Page 686 and 687:
2. Mr. P (paranoid schizophrenia)3.
Page 688 and 689:
2. Ms. M appears heavily sedated at
Page 690 and 691:
that?”21. Clozapine is prescribed
Page 692 and 693:
4. Other nonpharmacologic therapies
Page 694 and 695:
up his belongings36. As the charge
Page 696 and 697:
historian, and prolonged questionin
Page 698 and 699:
16. Ans: 3 Acknowledging feelings i
Page 700 and 701:
restlessness and agitation are the
Page 702 and 703:
C A S E S T U D Y 2 1702
Page 704 and 705:
QuestionsMs. N is a 20-year-old gra
Page 706 and 707:
5. Call a social worker for a consu
Page 708 and 709:
also get the Tdap vaccine. The clie
Page 710 and 711:
the student at this time that would
Page 712 and 713:
postpartum hemorrhage?1. Hypotensio
Page 714 and 715:
etonogestrel 68 mg. She is happy to
Page 716 and 717:
distress, neonatal death, necrotizi
Page 718 and 719:
18. Ans: 4 The heart rate and respi
Page 720 and 721:
therapeutic way but to always keep
Page 722 and 723:
Chapter 115. From Gray Morris D: Ca
Page 724 and 725:
Chapter 728. From Ignatavicius D, W
Page 726 and 727:
Chapter 1132. From Ignatavicius D,
Page 728 and 729:
Chapter 1331. From Ignatavicius D,
Page 730 and 731:
Chapter 1523. From Ogden SJ, Fluhar
Page 732 and 733:
Chapter 2142. From Aehlert B: EKGs
Page 734 and 735:
Case Study 133. From Ignatavicius D
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