NCLEX: Delegation

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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 things should an RN never delegate?

TIA= Teaching, IVs, and Assessments

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 airborne precautions important?

TB, varicella, or measles.

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 ambulate a newly admitted post-op/acutely ill patient?

An RN

Who should ambulate a one day P/O patient?

An LPN or an NA

Who should ambulate a stable medical & surgical patient?

An RN

Who should ambulate an acutely ill, chronic condition patient?

An LPN

Who should evaluate an initial post op patient's pain?

An RN

Who should evaluate a patients pain after a narcotic?

An RN or LPN

Who should establish a patient's initial plan of care?

An RN

Who should up date a patient's plan of care?

An RN or LPN

Who should manage a patient's on a vent for the first week (acute)?

An RN

Who should manage a patient on a vent after a week (chronic/stable)?

An LPN

Who should manage IVs for regular infusions, TPN, ABX, and drips?

The RN (LPN or NA should never manage IVs)

Who should take care of an SCI patient during their first week (acute)?

An RN

Who should take care of an SCI after a week (chronic/stable)?

An LPN

Who should transcribe orders?

An RN

Who should complete sterile procedures?

An RN or LPN

Who should teach self injections, dressing changes, or diets (except DM and CRF)?

An RN

Who should change sheets, get water for, enemas, stool spec/I&O for stable patients?

An NA

Who should transport a patient to an area within the hospital?

An NA

Who should feed a person with chronic parkinson's?

An NA

Who should feed a patient with an acute CVA?

An RN

Who should feed a patient with a chronic CVA?

An NA

Who should feed a new trach patient?

An RN

Who should feed a stable trach patient on a vent?

An LPN

Who should do an assessment on a new admit and new P/O patient?

An RN

Who should do an assessment on a stable acute patient?

An LPN

Who should do an assessment on a stable chronic patient?

An LPN

Who should take care of patients with airborne, droplet, or contact precautions?

An LPN

Who should administer medications?

An RN or LPN (no IVs)

Who should do the steps of the nursing process (assess, plan, interventions, outcomes)?

The RN

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 the doppler isn't reading?

Patient may not have pulses

What does it mean if the bladder scanner doesn't produce a reading?

Bladder is empty

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 there is no drainage from an NG tube?

Reposition patient or tube

What does it mean if the patient with an NG tube complains of N&V?

NG may be occluded so irrigate.

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 turns of alarms on equipment?

MORE EDUCATION

What should be done if staff uses extension cords for equipment?

MORE EDUCATION

What should be done if staff applies restraints to a patient to keep them from falling or wandering?

MORE EDUCATION

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?

MORE EDUCATION

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).

Who does an interdisciplinary team consist of?

MD, RN, PT, Social worker, etc.

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.

What should be done if someone is pulling out their IVs?

Put a mitten on them (least restrictive).

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 are the 2 general rules for vaccines?

No vaccine given if pt temp > 101 or on an antibiotic.

What is given to anyone with acute exposure to any infection or enlarged lymph nodes?

Immunoglobulins

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 egg?

MMR and flu shot

What is contraindicated with an allergy to iodine/shellfish?

Diagnostic test with dye/ cleaning solution for foleys/surgery.

What is contraindicated with an allergy to yeast?

Hepatitis B vaccine

What is contraindicated with an allergy to bananas, kiwi, chesnuts, an avocado?

Latex/rubber

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 sterile in the home?

IVs, dressings, and peritoneal dialysis.

What procedures are done non-sterile in the home?

Foley catheter, trach suctioning, insulin, injections, intermittent, and suprapublic catheters.

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