The delegator delegates tasks but no what?
Responsibility. Still legally responsible for the outcomes.
What do we need to know about delegating?
TELL= Taught (does the person know the skill), Evaluate (return demonstration), License (is one needed for the skill), and Lists (agency policy).
What is the ideal situation that is present on the NCLEX?
1 nurse, 1 patient, and all the time in the world. Assume all orders are written.
What types of activities should a nurse delegate to NAs?
Standard unchanging procedures and Stable patients only.
What are the rules to remember when delegating to NAs?
Can take VS on stable patients and 1/2 hour after blood is started, no tasks where medical knowledge is necessary, watch key words (show,explain, monitor, teach, check, assess, and demonstrate=NO), Can walk stable patients, reorient/co-conduct teaching w/an RN. NO: sterile procedures, assessments including VS on new admits, feeding choking risk patients, drugs (even OTC topicals), teaching, chest tubes, art lines, trachs, endo tubes, contagious diseases, or vents.
What are the rules to remember when delegating to an LPN?
An LPN works under direct supervision of an RN, in a nursing home they might be charge nurses and handle all aspects of care, Assign: stable chronic conditions c predictable outcomes (Pts 24 hours after surgery). NO: discharge planning, admission assessments (including VS), NO IVs, and NO teaching. CAN: give narcotics, have patient 72 hours after MI, CVA, SCI (spinal cord injury), Vents, or low coma scale (after 1 week), and may reinforce teaching.
What is the pneumonic for remembering who to see first (prioritizing patients)?
FIRST= Find hypoxia (oxygenation first-anxiousness), Immunocompromised (prevent infection), Rectal bleeding (hemorrhaging from major artery otherwise don't care- VS changes), Safety, and Try Infection (Ex: septic).
What are the rules for prioritizing patients?
Acute problems more serious than chronic, <24 hrs post op= more serious than medical conditions/older surgeries, unstable patient more serious than stable, when in doubt select the more vital organ (heart or lungs over toes/legs).
What patients are priority?
RLQ (appendix) pain, LLQ (diverticulosis) pain, mid epigastric pain (preg-seizure), spinal cord injury above T6, drooling child, central line c SOB, compartment syndrome (pain not relieved by drugs/cast or crushing injury c swelling), muffled heart sounds (cardiac tamponade), taking nitro within 1 week of MI (may be another), Femur/Pelvis fx c S&S of fat emboli, enlarged veins on Abd (portal HTN), DVT/PE, Immunocompromised pt with nonproductive cough (PCP) or temp, restlessness, abnormal electrolytes, progressive neurological diseases, burns c smoke inhalation, withdrawal symptoms of drugs/alcohol, angina c indigestion=MI, neuroleptic malignant syndrome, toxic levels of medication, and Spinal cord injury (SCI) c autonomic dysreflexia (crazy high BP).
What patients are NOT a priority?
RUQ (gallbladder) pain, Pain in the costovertebral angle (kidney stones), head trauma, bleeding, pain butt to ankle (sciatica), straining to urinate with bloody urine, menieres disease, chronic conditions, COPD, cystic fibrosis, laprascopy c chest or shoulder pain, Paperwork, calling doctor, teaching, high or low BS, Poop, FXs, obtaining lab studies, and Pain.
What causes a non priority patient to become priority?
Head trauma c INCREASED ICP, Bleeding FROM MAJOR ARTERY, Increased BS IN COMA, decreased BS C S&S OF SHOCK, Paperwork FOR PREOP CHECKLIST, Poop FROM AN SCI ABOVE T6 OR APPENDICITIS (STRAIN AND RUPTURE), lab studies- ABGs, chronic conditions C ACUTE LIFE THREATENING PROBLEM, pain- back: abdominal aortic aneurysm, RLQ: appendicitis, RLQ or back: ectopic pregnancy, or back pain with blood transfusions, angina c decreased LOC, decreased cardiac output = decreased urine output, arrhythmia, dizziness/faint.
In what order should patients be removed in the event of a disaster?
ABC= Ambulatory, bed ridden, and critical care patients.
What is the pneumonic to help you prioritize steps in the event of a fire?
RACE= Remove, Activate, Contain, and Extinguish.
What is the pneumonic to remember how to use the fire extinguisher?
PASS= Pull Pin, Aim, Squeeze, and Sweep
What is important to remember with room assignments?
If older than 6= must have a same sex roommate. RISK= Radiation (isolation), Infection/Immunocompromised/Isolation, Safety/Sex, and Know growth and development.
With which conditions are droplet precautions important?
Neisseria meningitis, mycoplasma pneumonia, strep group A, or pertussis.
WHAT IS THE PNEUMONIC TO REMEMBER THE PROPER TRIAGE PRIORITIES? (NEED TO KNOW WHO TO HELP!)
TRIAGE= Trauma-no internal injuries (breathing, bleeding, broken bones, burns), Respiratory (1st)/ Cardiac (2nd), ICP (LOC/seizure-airway), AN Infection (septic shock), GI (bleed, pain, and distention-not impt), Elimination-not impt (pyelonephritis or trouble voiding).
What should be done if someone is brought in with fixed and dilated pupils?
Nothing they are dead so go to the next person.
What should you be concerned about first with someone who experienced burns?
Airway and breathing bc if they were close enough to get burned they were close enough to inhale smoke.
What should be done if someone presents with dilated pupils and decreased LOC?
They probably have increased ICP so sit them up to help decrease the pressure.
What two things should you use to help determine appropriate delegation tasks for a UAP?
Their ability and demonstration of the task.
Who should manage IVs for regular infusions, TPN, ABX, and drips?
The RN (LPN or NA should never manage IVs)
RNs should delegate to what level of a person's confidence? Based on?
Highest level of confidence and based on experience, training, and licensure.
What does it mean if the glucometer isn't giving a reading?
There isn't enough blood to get a reading.
What does it mean if a PCA pump isn't delivering medication to the patient?
The may be asking to often or not enough medication to control the pain.
What does it mean if the vent is beeping with a high pressure alarm?
The patient is causing problems (fighting the vent- holding breath,etc.).
What does it mean if the vent is beeping with a low pressure alarm?
There is a problem with the machine so get a new one and send the broken one to biomed engineering to have it fixed.
What does it mean if an O2 mask with a rebreather bag deflates during inspiration?
The bag should NEVER deflate so get new equipment.
What does it mean if there is no pulse ox reading?
It's on too fat of a finger or no light is seen through the finger. Put it on another location.
What does it mean if the pulse ox is not alarming when O2 is at 92%?
Check the alarm level settings. May be too low and need readjusted.
What does it mean if the pulse ox read 100% but patient is restless?
Patient may have been exposed to carbon monoxide.
What should be done if an IV pump (IVAC) set to run 1 liter of fluid at 150 ml/hr after 6 hours there is 200 ml left in the bag?
Send to biomed engineering and obtain another pump.
What does it mean if there is continuous bubbling in the H20 seal chamber of a chest tube?
There is an air leak so a new Plurovac should be used.
What should be done if a peritoneal dialysis machine (CAPD) shows 2000 ml in and 1500 ml cloudy output?
Reposition patient and call MD.
What should be done if the pyxis doesn't deliver a stat medication?
Filled Q24 hours so call the pharmacy for the med.
What should be done if a cooling blanket is on a patient with a temp of 38 C (100.4 F), then after three hours their temp is 102F?
Send to biomed engineering and obtain a new cooling blanket.
What should be done if a pressure ulcer vacuum device has no suction?
Check to see if the tape is loose.
What should be done if an Oto thermometer isn't registering?
Check charge or send to biomed engineering and obtain new.
What does it mean if a patients pacemaker is set at 75 and the patients rate is 80?
It OK and working fine. The patients heart can do better than the pacemaker just no worse!
What does it mean if the patients pacemaker is set at 75 and the patient's rate is 60?
It is defective and the MD should see the patient.
What should be done if staff applies restraints to a patient to keep them from falling or wandering?
What should be done if staff doesn't recognize false imprisonment such as gerichair c tray, not allowing patient to leave w/o MD orders, or anything preventing freedom to move about?
What should be done if staff breaches confidentiality (taking in public areas, giving D/C instructions with others in room, teaching with family in room, calling support groups w/o pt permission?
MORE EDUCATION. NURSE MANAGER OFFICE IS NOT OPEN TO THE GENERAL PUBLIC (=safe place to discuss).
For whom does the interdisciplinary team meet?
For those with chronic non compliance issues (Ex: sickle cell admitted 3x for crisis, DM admitted for hyperglycemia, celiac not gaining weight, asthma admitted for bronchospasms several times a year).
What types of conditions doesn't the interdisciplinary team not meet for?
Chronic stable conditions that are compliant and/or resolved by surgery or medical management (Ex: Pyloric stenosis, cleft lip, nephritis, glomerulonephritis, multiple fx after MVA, and acute leukemia on chemo).
What should be taught regarding home safety?
Bikes & skateboards should not be ridden in the street, guns should not be in homes with children even if they are locked up, <1 year old=sit in back seat facing backward >1 yr & <12 yrs= sit in back seat facing forward, home oxygen should be kept away from flames (stove, fireplace, no wool blankets, and no smoking- the smoke itself won't cause an explosion).
Who is at risk for falling blind/deaf patients or those with canes/walkers/or small animals?
Those with canes/walkers/small animals (geriatrics) are at risk for falling.
Who should an NA never position?
Total Hip replacement, total knee replacement, Increased ICP, acute CVA, or Above knee/below knee amputations.
What should be your response to Non-patient/non-medical issues that arise?
Tell direct supervisor (Ex: staff eating off of patient's trays).
What should be your response when a patient will be harmed d/t lack of intervention?
Intervene immediately and do procedure correctly. (Ex: Staff contaminating foley).
What should be your response if a staff members action is incorrect but will not harm the patient?
Wait until they are finished then teach the correct procedure to them.
If there is a problem that requires immediate attention when should you call the doctor?
After you have initiated an ACTIVE INTERVENTION. If it is serious enough to call the Dr. then need something to keep them alive until Dr. gets there.
What should be included in change of shift report?
Changes in condition, new medications, complications, diagnostic procedures, treatments (lasix for crackles, etc.)
Which of these is within the RN scope of practice? Starting IVs, Isolation placement, Problem w/NGs, and Room assignments.
All are within the RN scope of practice.
What three things should the Dr. be called for?
Acute epiglottitis, back pain (Abdominal Aortic Aneurysm (triple A)), and Eye Pain (glaucoma or cataract surgery). Only call MD for abnormal situations not what is expected.
What is important to remember about prioritizing in the ER?
It won't be the obvious answer and don't be swayed by adjectives.
What should pregnant nurses avoid?
5th disease (slapface/Parovirus), measles, varicella, internal radiation, isotopes, and chemo drug handing.
What information do you need to know prior to starting your shift?
Blood sugars, pre-ops, post-ops, change of condition on last shift, and new admits.
What is important to know about evaluating a treatment?
All drugs/tx are used to bring a pt back to normal. A successful tx will always reverse the presenting signs and symptoms (ask why treatment initiated).
How are patients on the psych ward prioritized?
1st: Physiological, 2nd: Change in psych behavior, 3rd: Safety
Who should floaters be assigned to?
To patients with a condition similar to what they would see on their own floor, and most stable person possible, NEVER cardiac patients or borderline/antisocial patients (will eat them up bc so manipulative).
What kinds of patients could be assigned to an OB float nurse?
Closed abdominal surgeries, HTN, DM, Epidurals, and IV drips. If cardiac maybe telemetry bc similar.
What kinds of patients could be assigned to a medical surgical float nurse?
DM, DVT, HTN, SURGERIES, CHRONIC CONDITIONS, AND SEIZURES.
What types of patients should never be transferred from the OB floor to the med surg floor?
Moms c babies, in labor, or c complications
What patients are immunocompromised?
HIV, cancer, chemo, steroids, organ transplants, cushings, addisons, and radiation.
What kills the immunocompromised patients?
Infection, live viruses (oral polio or varicella), Pneumocystis Carnii Pneumonia (PCP) (danger to immcprd pts only).
What are examples of progressive neurological diseases? What kind of death do they suffer from?
Multiple Sclerosis, Amynotrophic lateral Sclerosis (ALS), Parkinsons, Huntingtons Chorea, Gullian Barre Syndrome, Myasthenia Gravis, and Scleroderma (hardening). THEY DIET A RESPIRATORY DEATH.
What are interventions for a patient with a progressive neurological disease who may have respiratory problems as a result?
Use peak flow meter, get advanced directive, mechanical soft diet, and thickened liquids.
What should be done for effective infection control?
ID type of precautions required (airborne, droplet, contact, or standard), put infected patients in private rooms or with patient c same organism, airborne in private room with negative pressure (TB), Droplet (mask within 3 feet), contact (gown & gloves), and infected patients can leave room as long as wear same PPE out of room as ppl wear going into the room.
Who should be isolated?
Pt with night sweats/temp/ and cough (TB), Pt with HA and stiff neck (meningitis), adult patient with rash or blisters (shingles), and any patient showing S&S of infection (increased temp, rash, increased WBCs) until verified. Follow CDC guidelines.
What type of patient should be discharged during an emergency?
Select patient with stable chronic condition. DO NOT discharge acute surgical patients. Pressure ulcers are considered chronic.
What should be done 1st and 2nd if the event of a med error, pt injury, or attempted suicide?
1st provide care, and 2nd notify MD.
What meds/herbs should you make sure to ask patients if they are taking (so can implement bleeding precautions)?
NSAIDS, ASA, Heparin, Coumadin, Garlic, Ginkgo, Ginseng, and Vitamin E.
What patients are on bleeding precautions?
On coumadin/heparin, hemophilia, problems with bone marrow, chemo, liver disease, HIV, DIC, ASA/NSAIDS, and Cancer.
Patients on/with what should never be sent to surgery?
ANTICOAGULATED PATIENTS: With low platelets, high PT or PTT, or on coumadin/heparin.
What should be given to a patient on coumadin before they have surgery? When should it be given?
Aqua Mephyton (Vitamin K) is needed b4 surgery for someone on coumadin so they don't bleed out (it helps coagulation). If it is D/C 24 hours before they may still bleed because it's not long enough prior to surgery so Vit K will help.
What needs to be done prior to transferring patient to another unit?
Receiving unit must be familiar with the disease/treatment, be alert for gender specific wards (OB), don't transfer (unstable pts, unknown diagnosis pts, or pt whose condition is made worse with stress (addisons, lupus, RA, raynauds, asthma, etc.).
What adults should be transferred to the Peds ward if necessary?
Adult with condition/tx similar to that which is seen in the pediatric population. (COPD is like cystic fibrosis, pneumonia is pneumonia).
How should Peds patients be transferred to the Med Surg floor?
Oldest child 1st, No communicable diseases, Not immunocompromised, and No teaching needed.
What conditions require seizure precautions?
Cirrhosis encephalopathy, PIH (HTN), DTs, ICP, CVA, Meningitis, Brain surgery, and Head trauma.
What interventions are needed to prevent aspiration?
HOB elevated to eat, bed in low position, place on right side after eating, call bell in reach, suction available, and side rails elevated.
What is given to anyone with acute exposure to any infection or enlarged lymph nodes?
What should be done for pain and discomfort?
Avoid drugs, use nursing interventions (positioning, heat, etc.), when in doubt flush the patient out.
What is contraindicated with an allergy to iodine/shellfish?
Diagnostic test with dye/ cleaning solution for foleys/surgery.
What should you NEVER Massage?
Veins, Z-track, Pressure ulcers, SQ heparin, Wilm's tumor, and intradural (PPD TB test).
For what things should you use massage?
To decrease PAD pain, claudication (pain with walking) and increase circulation= increased O2 and decreased pain, prevent hemorrhage after delivery, decrease neuropathy, after bleeding stop hemophiliac.
What procedures are done non-sterile in the home?
Foley catheter, trach suctioning, insulin, injections, intermittent, and suprapublic catheters.
An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? (Select all that apply)
1. Auscultate breath sounds
2. Administer medications via metered-dose inhaler (MDI)
3. Complete in-depth admission assessment
4. Initiate the nursing care plan
5. Evaluate the patient's technique for using MDI's
ANS: 1, 2, 4
Rationale: The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN. Independently completing the admission assessment, initiating the nursing care plan, and evaluating a patient's abilities require additional education and skills. These actions are withing the scope of practice of the professional RN
You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you immediately?
1. The patient has fine bibasilar crackles
2. The patient's respiratory rate is 8 breaths/min.
3. The patient sits up and leans over the night table.
4. The patient has a large barrel chest.
Rationale: For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This patient's oxygen flow is too high and is causing a high serum oxygen level, which results in a decreased respiratory arrest. Crackles, barrel chest, and assumption of a sitting position leaning over the night table are common in patients with chronic emphysema
The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient's comfort for this problem?
1. Suggest that the patient's oxygen be humidified
2. Suggest that a simple face mask be used instead of a nasal cannula.
3. Suggest that the patient be provided with an extra pillow
4. Suggest that the patient sit up in a chair at the bedside
Rationale: When the oxygen flow rate is higher than 4 L/min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Application of a water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem
You are supervising a student nurse who is performing tracheostomy care for a patient. For which action by the student should you intervene?
1. Suctioning the tracheostomy tube before performing tracheostomy care
2. Removing old dressings and cleaning off excess secretions
3. Removing the inner cannula and cleaning using universal precautions
4. Replacing the inner cannula and cleaning the stoma site.
5. Changing the soiled tracheostomy ties and securing the tube in place
Rationale: When tracheostomy care is performed, a sterile field is set up and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when preforming tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate.
You are supervising an RN who was pulled from the medical-surgical floor to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which of these directions would you clearly proved to the RN? (Select all that apply)
1. Position the patient supine and turned on his side
2. Apply direct lateral pressure to the nose for 5 minutes
3. Maintain universal body substances precautions.
4. Apply ice or cool compresses to the nose
5. Instruct the patient not to blow the nose for several hours.
ANS: 2, 3, 4, 5
Rationale: The correct position for a patient with an anterior nosebleed is upright and leaning forward to prevent blood from entering the stomach and avoid aspiration. All of the other instructions are appropriate according to best practice for emergency care of a patient with an anterior nosebleed
A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant (PCT)?
1. Discuss weight-loss strategies such as diet and exercise with the patient
2. Teach the patient how to set up the BiPAP machine before sleeping
3. Remind the patient to sleep on his side instead of his back.
4. Administer modafinil (Provigil) to promote daytime wakefulness
Rationale: The nursing assistant can remind patients about actions that have already been taught by the nurse and are part of the patient's plan of care. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can delegate administration of medication to an LPN/LVN
You are acting as preceptor for a newly graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide care to which patients? (Select all that apply)
1. A 38-year old with moderate persistent asthma awaiting discharge
2. A 63-year old with a tracheostomy needing tracheostomy care every shift.
3. A 56-year old with lung cancer who has just undergone left lower lobectomy
4. A 49-year old just admitted with a new diagnosis of esophageal cancer.
ANS: 1, 2
Rationale: The new RN is at an early point in her orientation. The most appropriate patients to assign to her are those in stable condition who require routine care. The patient with the lobectomy will require the care of a more experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. As the new nurse advances through her orientation, you will want to work with her in providing care for these patients with more complex needs
You are providing care for a patient with recently diagnosed asthma. Which key points would you be sure to include in your teaching plan for this patient? (Select all that apply)
1. Avoid potential environmental asthma triggers such as smoke
2. Use the inhaler 30 minutes before exercising to prevent bronchospasm
3. Wash all bedding in cold water to reduce and destroy dust mites.
4. Be sure to get at least 8 hours of rest and sleep every night.
5. Avoid foods prepared with monosodium glutamate (MSG)
ANS: 1, 2, 4, 5
Rationale: Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma.
You are a team leader RN working with a student nurse. The student nurse is to teach a patient how to use and MDI without a spacer. Put in correct order the steps that the student nurse should teach the patient.
1. Remove the inhaler cap and shake the inhaler
2. Ope your mouth and place the mouthpiece 1 to 2 inches away
3. Tilt your head back and breathe out fully
4. Hold your breath for at least 10 seconds
5. Press down firmly on the canister and breathe deeply through your mouth
6. Wait at least 1 minute between puffs..
____, ____, ____, ____, ____, ____
ANS: 1, 3, 2, 5, 4, 6
Rationale: Before each use, the cap is removed and the inhaler is shaken according to the instructions in the package insert. Next the patient should tilt the head back and breathe out completely. As the patient begins to breathe in deeply through the mouth, the canister should be pressed down to release one puff (dose) of the medication. The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs. The patient should wait for at least 1 minute between puffs from the inhaler
A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (PCT)?
1. Assisting the patient to sit up on the side of the bed
2. Instructing the patient to cough effectively
3. Teaching the patient to use incentive spirometry
4. Auscultating breath sounds every 4 hours
Rationale: Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of a nursing assistant. Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate for a licensed nurse
The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision?
1. Observe how well the patient performs pursed-lip breathing
2. Plan a nursing care regiment that gradually increases activity intolerance
3. Assist the patient with basic activities of daily living
4. Consult with the physical therapy department about reconditioning exercises
Rationale: Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to a nursing assistant. Planning and consulting require additional education and skills, appropriate to an RN
The patient with COPD tells the nursing assistant that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the nursing assistant to report which of these?
1. Blood pressure of 152/84 mm Hg
2. Respiratory rate of 27 breaths/min
3. Heart rate of 92 beats/min
4. Oral temperature of 101.2 F (38.4C)
Rationale: A patient who did not have the pneumonia vaccination or flu shot is at increased risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection, which may be respiratory in origin. All of the other vital sign values are slightly elevated but are not a cause for immediate concern.
You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given a nursing diagnosis of Activity Intolerance. Which action should you delegate to the nursing assistant?
1. Instructing the patient to alternate rest and activity periods
2. Encouraging, monitoring, and recording nutritional intake
3. Monitoring cardiorespiratory response to activity
4. Planning activities for periods when the patient has the most energy
Rationale: The nursing assistant's training includes how to monitor and record intake and output. After the nurse has taught the patient about the importance of adequate nutritional intake for energy, the nursing assistant can remind and encourage the patient to take in adequate nutrition. Instructing patients and planning activities require more education and skill, and are appropriate to the RN's scope of practice. Monitoring the patient's cardiovascular response to activity is a complex process requiring additional education, training, and skill, and falls within the RN's scope of practice
You are supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would you clearly instruct the nursing student to notify you about immediately?
1. Chest tube drainage of 10 to 15 mL/hr
2. Continuous bubbling in the water seal chamber
3. Complaints of pain at the chest tube site
4. Chest tube dressing dated yesterday
Rationale: Continuous bubbling indicates an air leak that must be identified. With the physician's order you can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion, which will require you to notify the physician. If the air bubbling does not stop when you apply the padded clamp, the air leak is between the clamp and the drainage system, and you must assess the system carefully to locate the leak. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. The patient's complaints of pain need to be assessed and treated. This is important but is not as urgent as investigating a chest tube leak.
After change of shift, you are assigned to care for the following patients. Which patient should you assess first?
1. A 68-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab
2. A 57-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation
3. A 72-year old with pneumonia who needs to be started on intravenous (IV) antibiotics
4. A 52-year old with asthma who complains of shortness of breath after using a bronchodilator
Rationale: The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations are urgent. in COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable.
You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to a nursing assistant?
1. Teaching the patient about the importance of adequate of fluid intake and hydration.
2. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed
3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake
4. Encouraging the patient to take a deep breath, hold it for 2 seconds, then cough two or three times in succession.
Rationale: A nursing assistant can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic nursing assistant. However, an experienced nursing assistant could assist the patient with positioning after the nursing assistant and the patient had been taught the proper technique. The nursing assistant would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill, and is within the scope of practice of the RN
The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit?
1. A 58-year old on airborne precautions for tuberculosis (TB)
2. A 68-year old just returned from bronchoscopy and biopsy
3. A 72-year old who needs teaching about the use of incentive spirometry
a 69-year old with COPD who is ventilator dependent
Rationale: Many surgical patients are taught about coughing, deep breathing, and use of incentive spirometry preoperatively. To care for the patient with TB in isolation, the nurse must be fitted for a high-effeciency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.
When a patient with TB is being prepared for discharge, which statement by the patient indicates the need for further teaching?
1. "Everyone in my family needs to go and see the doctor for TB testing"
2. "I will continue to take my isoniazid until I am feeling completely well
3. "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag.
4. "I will change my diet to include more foods righ in iron, protein, and vitamin C
Rationale: Patients taking isoniazid must continue the drug for 6 months. The other 3 statements are accurate and indicate understanding of TB. Family members should be tested because of their repeated exposure to the patient. Covering the nose and mouth when sneezing or coughing, and placing the tissues in plastic bags help prevent transmission of the causative organism. The dietary changes are recommended for patients with TB
You are admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus?
1. The patient was recently in a motor vehicle accident
2. The patient participated in an aerobic exercise program for 6 months
3. The patient gave birth to her youngest child 1 year ago
4. The patient was on bed rest for 6 hours after a diagnostic procedure
Rationale: Patients who have recently experienced trauma are at risk for deep vein thrombosis and pulmonary embolus. None of the other findings are risk factors for pulmonary embolus. Prolonged immobilization is also a risk factor for DVT and pulmonary embolus, but this period of bed rest was very short.
Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team?
1. Evaluating the patient's complaint of chest pain
2. Monitoring laboratory values for changes in oxygenation
3. Assessing for symptoms of respiratory failure
4. Auscultating the lungs for crackles
Rationale: An LPN who has been trained to auscultate lungs sounds can gather data by routine assessment and observation, under supervision of an RN. Independently evaluating patients, assessing for symptoms of respiratory failure, and monitoring and interpreting laboratory values require additional education and skill, appropriate to the scope of practice of the RN
A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? (Select all that apply)
1. Use a lift sheet when moving and positioning the patient in bed
2. Use an electric razor when shaving the patient each day
3. use a soft-bristled toothbrush or tooth sponge for oral care
4. Use a rectal thermometer to obtain a more accurate body temperature
5. Be sure the patient's footwear has a firm sole when the patient amubulates
ANS: 1, 2, 3, 5
Rationale: While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). All of the other instructions are appropriate to the care of a patient receiving anticoagulants.
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action?
1. Perform endotracheal intubation and initiate mechanical ventilation
2. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth
3. Administer furosemide (Lasix) 100 mg IV push stat
4. Call a code for respiratory arrest
Rationale: A non-rebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient's work of breathing.
You are the preceptofor an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately?
1. Assessing for bilateral breath sounds and symmetrical chest movements
2. Auscultating over the stomach to rule out esophageal intubation
Marking the tube 1 cm from where it touches the incisor tooth or nares
4. Ordering a chest radiograph to verify that tube placement is correct
Rationale: The endotracheal tube should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after endotracheal placement. The priority at this time is to verify that the tube has been correctly placed.
You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced nursing assistant?
1. Assessing the patient's respiratory status every 4 hours
2. Taking vital signs and pulse oximetry readings every 4 hours
3. Checking the ventilator settings to make sure they are as prescribed
4. Observing whether the patient's tube needs suctioning every 2 hours
Rationale: The nursing assistant's educational preparation includes measurement of vital signs, and an experienced nursing assistant would know how to check oxygen saturaton by pulse oximetry. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN
After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the RN immediately?
1. Heart rate of 98 beats/min
2. Respiratory rate of 24 breaths/min
3. Blood pressure of 168/90 mm Hg
4. Tympanic temperature of 101.4 F (38.6 C)
Rationale: Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the respiratory system.
You are making a home visit to a 50-year old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism. The patient's only medication is enoxaparin (Lovenox) subcutaneously. Which assessment information will you need to communicate to the physician?
1. The patient says that her right leg aches all night
2. The right calf is warm to the touch and is larger than the left calf
3. The patient is unable to remember her husband's first name
4. There are multiple ecchymotic areas on the patient's arms
Rationale: Confusion in a patient this age is unusual and may be an indication of intracerebral bleeding associated with enoxaparin use. The right leg symptoms are consistent with a resolving deep vein thrombosis; the patient may need teaching about keeping the right leg elevated above the heart to reduce swelling and pain. The presence of ecchymoses may point to a need to do more patient teaching about avoiding injury while taking anticoagulants but does not indicate that the physician needs to be called.
The high-pressure alarm on a patient's ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next?
1. Reassure the patient that the ventilator will do the work of breathing for him
2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm
3. Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning
4. Insert an oral airway to prevent the patient from biting on the endotracheal tube
Rationale: Manual ventilation of the patient will allow you to deliver an Fio2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, and/or insertion of an oral airway, but the first step should be assessment of the reason for the high-pressure alarm and resolution of the hypoxemia
When assessing a 22-year old patient who required emergency surgery and multiple transfusion 3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate>
1. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes
2. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs
3. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilatoin
4. Switch the patient to a nonrebreater mask at 95% to 100% oxygen and call the physician to discuss the patient's status.
Rationale: The patient's history and symptoms suggest the development of ARDS, which will require intubation and mechanical ventilation. The maximum oxygen delivery with a nasal cannula is an Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.
You have just finished assisting the physician with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is important to report to the physician?
1. The patient starts crying and says she can't go on with treatment much longer
2. The patient complains of sharp, stabbing chest pain with every deep breath
3. The patient's blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min
4. The patient's dressing at the thoracentesis site has 1 cm of bloody drainage
Rationale: Removal of large quantities of fluid from the pleural space can cause fluid to shift from the circulation into the pleural space, causing hypotension and tachycardia. The patient may need to receive IV fluids to correct this. The other data indicate that the patient needs ongoing monitoring and/or interventions but would not be unusual findings for a patient with this diagnosis or after this procedure
You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotraceal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care?
1. Administer ordered antibiotics as scheduled
2. Hyperoxygenate the patient before suctioning
3. Maintain the head of the bed at a 30 - to 45-degree angle
4. Suction the airway when coarse crackles are audible
Rationale: Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP
Which of these medication orders for a patient with a pulmonary embolism is more important to clarify with the prescribing physician before admnistration?
1. Warfarin (Coumadin) 1.0 mg by mouth (PO)
2. Morphine sulfate 2 to 4 mg IV
3. Cephalexin (Keflex) 250 mg PO
4. Heparin infusion at 900 units/hr
Rationale: Medication safety guidelines indicate that use of a trailing zero is not appropriate when writing medication orders because the order can easily be mistaken for a larger dose, such as 10 mg. The order should be clarified before administration. The other orders are appropriate, based on teh patient's diagnosis.
A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient's care?
1. Perform postural drainage and chest physiotherapy every 4 hours
2. Allow the patient to decide whether she needs aerosolized medications
3. Place the patient in a private room to decrease the risk of further infection
4. Plan activities to allow at least 8 hours of uninterrupted sleep
Rationale: Airway clearance techniques are critical for patients with cystic fibrosis and should take priority over the other activities. Although allowing more independent decision making is important for adolescents, the physiologic need for improved respiratory function takes precedence at this time. A private room may be desirable for the patient but is not necessary. With increased shortness of breath, it will be more important that the patient have frequent respiratory treatments than 8 hours of sleep.
You have obtained the following assessment information about a 3-year old who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow-up?
1. Frequent swallowing
2. Hypotonic bowel sounds
3. Complaints of a sore throat
4. Heart rate of 112 beats/min
Rationale: Frequent swallowing after a tonsillectomy may indicate bleeding. You should inspect the back of the throat for evidence of bleeding. The other assessment results are not unusual in a 3-year old after surgery
You are providing nursing care for a newborn infant with respiratory distress syndrome (RDS) who is receiving nasal CPAP ventilation. What complications should you monitor for this infant?
1. Pulmonary embolus
Rationale: The most common complications after birth for infants with RDS is pneumothorax. Alveoli rupture and air leaks into the chest and compresses the lungs, which makes breathing difficult
To improve respiratory status, which medication should you be prepared to administer to the newborn infant with RDS?
1. Theophylline (Theolair, Theochron)
2. Surfactant (Exosurf)
3. Dexamethasone (Decadron)
4. Albuterol (Proventil)
Rationale: Exosurf enonatal is a form of synthetic surfactant. An infant with RDS may be given two to four doses during the first 24 to 48 hours after birth. It improves respiratory status, and research has show a significant decrease in the incidence of pneumothorax when it is administered.