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Chapter 4 - Prioritization, Delegation, and Assignment
The RN is admitting a client with benign prostatic hyperplasia (BPH) to an acute care unit. The client describes an oral intake of about 1400 mL/day. What is the RN's priority concern? •Ask the client about his or her bowel movements •Have the client complete a diet diary for the past 2 days •Instruct the client to increase oral intake to 2 to 3 L/day •Ask the client to describe his urine output ✔✔•Instruct the client to increase oral intake to 2 to 3 L/day •An adult should take in about 2 to 3 L of fluid daily from food and liquids. Although the RN would want to know about bowel movements, dietary intake, and urine output, in this case, the priority is that the client is not taking in enough oral fluids. The client has fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to unlicensed assistive personnel (UAP)? •Administering IV fluids as prescribed by the physician •Providing straws and offering fluids between meals •Developing a plan for added fluid intake over 24 hours •Teaching family members to assist the client with fluid intake ✔✔•Providing straws and offering fluids between meals •UAPs can reinforce additional fluid intake when it is part of the care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice of an RN. The unlicensed assistive personnel (UAP) reports to the nurse that a client's urine output for the past 24 hours has been only 360 mL. What is the nurse's priority action at this time? •Place an 18-gauge IV in the nondominant arm •Elevate the client's head of bed at least 45 degrees •Instruct the UAP to provide the client with a pitcher of ice water •Contact and notify the health care provider immediately ✔✔•Contact and notify the health care provider immediately •The minimum amount of urine per day needed to excrete toxic waste products is 400 to 600 mL. This minimum volume is called the obligatory urine output. If the 24-hour urine output falls below the obligatory output amount, wastes are retained and can cause lethal electrolyte imbalances, acidosis, and a toxic buildup of nitrogen. The client may need additional fluids (IV or oral) after the cause of the low urine output is determined. Elevating the head of the bed will not help with urine output. Notifying the health care provider is the first priority in this case. The client described in question 3 is also at risk for poor perfusion related to decreased plasma volume. Which assessment finding supports this risk?
•Flattened neck veins when the client is in the supine position •Full and bounding pedal and post-tibial pulses •Pitting edema located in the feet, ankles, and calves •Shallow respirations with crackles on auscultation ✔✔•Flattened neck veins when the client is in the supine position •Normally, neck veins are distended when the client is in the supine position. These veins flatten as the client moves to a sitting position. The other three responses are characteristic of excess fluid volume. The nursing care plan for an older client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? Select all that apply. •Reminding the client to avoid commercial mouthwashes •Encouraging mouth rinsing with warm saline •Assess skin turgor by pinching the skin over the back of the hand •Observing the lips, tongue, and mucous membranes •Providing mouth care every 2 hours while the client is awake •Seeking a dietary consult to increase fluids on meal trays ✔✔•Reminding the client to avoid commercial mouthwashes •Encouraging mouth rinsing with warm saline •Observing the lips, tongue, and mucous membranes •Providing mouth care every 2 hours while the client is awake •The LPN/LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPNs/LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes, which contain agents such as alcohol. To assess skin turgor in an older adult, skin tenting is best checked by pinching the skin over the sternum or on the forehead rather than the back of the hand. With aging, the skin loses elasticity and tents on hands and arms even when the adult is well hydrated. Initiating a dietary consult is within the purview of the RN or health care provider. The health care provider has written these orders for a client with a diagnosis of pulmonary edema. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? •Weigh the client every morning •Maintain accurate intake and output records •Restrict fluids to 1500 mL/day •Administer furosemide 40 mg IV push ✔✔•Administer furosemide 40 mg IV push •Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. The other orders are important but are not urgent.
•Hypokalemia •Hyperkalemia •Hyponatremia •Hypernatremia ✔✔•Hyponatremia •SIADH results in a relative sodium deficit caused by excessive retention of water. The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to a new- graduated RN. Which actions can the new-graduate RN delegate to the unlicensed assistive personnel (UAP)? Select all that apply. •Providing oral care every 3 to 4 hours •Monitoring for indications of dehydration •Administering 0.45% saline by IV line •Record urine output when client voids •Assessing daily weights for trends •Help the client change position every 2 hours ✔✔•Providing oral care every 3 to 4 hours •Record urine output when client voids •Help the client change position every 2 hours •Providing oral care, assisting clients to reposition, and recording urine output are within the scope of practice of the UAP. Monitoring and assessing clients, as well as administering IV fluids, require the additional education and skills of the RN. An experienced LPN/LVN reports to the RN that a client's blood pressure and heart rate have decreased, and when his face was assessed, one side twitches. What action should the RN take at this time? •Reassess the client's blood pressure and heart rate •Review the client's morning calcium level •Request a neurologic consult today •Check the client's pupillary reaction to light ✔✔•Review the client's morning calcium level •A positive Chvostek sign (facial twitching of one side of the mouth, nose, and cheek in response to tapping the face just below and in front of the ear) is a neurologic manifestation of hypocalcemia. The heart rate may be slower or slightly faster than normal, with a weak, thready pulse. Severe hypocalcemia causes severe hypotension. The LPN/LVN is experienced and possesses the skills to accurately measure vital signs. The nurse is preparing to discharge a client whose calcium level was low but is now just barely within the normal range (9 to 10.5 mg/dL [2.25 to 2.63 mmol/L]). Which statement by the client indicates the need for additional teaching? •"I will call my doctor if I experience muscle twitching or seizures." •"I will make sure to take my vitamin D with my calcium each day." •"I will take my calcium citrate pill every morning before breakfast."
•"I will avoid dairy products, broccoli, and spinach when I eat." ✔✔•"I will avoid dairy products, broccoli, and spinach when I eat." •Clients with low calcium levels should be encouraged to eat dairy products, seafood, nuts, broccoli, and spinach, which are all good sources of dietary calcium. The other three options indicate correct understanding of calcium therapy. Which order prescribed for a client with hypercalcemia would the nurse be sure to question? •0.9% saline at 50 mL/hr IV •Furosemide 20 mg orally each morning •Apply cardiac telemetry monitoring •Hydrochlorothiazide (HCTZ) 25 mg orally each morning ✔✔•Hydrochlorothiazide (HCTZ) 25 mg orally each morning •Calcium excretion is decreased with thiazide diuretics (e.g., HCTZ), so the calcium level is at risk for going even higher. Loop diuretics (e.g., furosemide) increase calcium excretion. The addition of IV fluids and cardiac monitoring are appropriate actions for monitoring and treating a client with hypercalcemia. The unlicensed assistive personnel (UAP) asks the nurse why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is the RN's best response? •"The client's low phosphorus is probably due to malnutrition." •"The client is just worn out from not getting enough rest." •"The client's skeletal muscles are weak because of the low phosphorus." •"The client will do more for himself when his phosphorus level is normal." ✔✔•"The client's skeletal muscles are weak because of the low phosphorus." •A musculoskeletal manifestation of low phosphorus levels is generalized muscle weakness, which may lead to acute muscle breakdown (rhabdomyolysis). Phosphate is necessary for energy production in the form of adenosine triphosphate, and when not produced, leads to generalized muscle weakness. Although the other statements are true, they do not answer the UAP's question. The RN is reviewing the client's morning laboratory results. Which of these results is of most concern? •Serum potassium level of 5.2 mEq/L (5.2 mmol/L) •Serum sodium level of 134 mEq/L (134 mmol/L) •Serum calcium level of 10.6 mg/dL (2.65 mmol/L) •Serum magnesium level of 0.8 mEq/L (0.4 mmol/L) ✔✔•Serum magnesium level of 0.8 mEq/L (0. mmol/L)
•Assisting the client to reposition every 2 hours •The UAP's training and education includes how to measure vital signs, record intake and output, and reposition clients. Performing fingerstick glucose checks and assessing clients requires additional education and skill, as possessed by licensed nurses. Notifying the provider of glucose changes is within the scope of practice for licensed nurses. Some facilities may train experienced UAPs to perform fingerstick glucose checks and change their role descriptions to designate their new skills, but this task is beyond the normal scope of practice of a UAP. The nurse is admitting an older adult client to the acute care medical unit. Which assessment factor alerts the nurse that this client has a risk for acid-base imbalances? •History of myocardial infarction (MI) 1 year ago •Antacid use for occasional indigestion •Shortness of breath with extreme exertion •Chronic renal insufficiency ✔✔•Chronic renal insufficiency •Risk factors for acid-base imbalances in older adults include chronic kidney disease and pulmonary disease. Occasional antacid use will not cause imbalances, although antacid abuse is a risk factor for metabolic alkalosis. The MI occurred 1 year ago and is no longer a risk factor. A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse assesses the client, which finding would the nurse instruct the student to report immediately? •Respiratory rate of 8 to 10 breaths/min •Decrease in pain level from 6 to 2 (on a scale of 1 to 10) •Request by the client that the room door be closed •Heart rate of 90 to 100 beats/min ✔✔•Respiratory rate of 8 to 10 breaths/min •A decreased respiratory rate indicates respiratory depression, which also puts the client at risk for respiratory acidosis. All of the other findings are important and should be reported to the RN, but the respiratory rate demands urgent attention. The unlicensed assistive personnel (UAP) reports to the nurse that a client seems very anxious, and vital sign measurement included a respiratory rate of 38 breaths/min. Which acid-base imbalance should the nurse suspect? •Respiratory acidosis •Respiratory alkalosis •Metabolic acidosis •Metabolic alkalosis ✔✔•Respiratory alkalosis •The client is most likely hyperventilating and blowing off carbon dioxide. This decrease in carbon dioxide will lead to an increase in pH and cause respiratory alkalosis. Eliminating carbon dioxide would lead to an alkalosis. Metabolic imbalances would be related to renal changes.
A client is admitted to the oncology unit for chemotherapy. To prevent an acid-base problem, which finding would the nurse instruct the unlicensed assistive personnel (UAP) to report? •Repeated episodes of nausea and vomiting •Reports of pain associated with exertion •Failure to eat all the food on the breakfast tray •Client hair loss during the morning bath ✔✔•Repeated episodes of nausea and vomiting •Prolonged nausea and vomiting can result in acid deficit that can lead to metabolic alkalosis. The other findings are important and need to be assessed but are not related to acid-base imbalances. The client has a nasogastric (NG) tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate and depth has decreased. What is the nurse's best response? •"It's common for clients with uncomfortable equipment such as NG tubes to have a lower rate of breathing." •"The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism." •"Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps correct the problem." •"The client is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis." ✔✔•"The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism." •Nasogastric suctioning can result in a decrease in acid components and metabolic alkalosis. The client's decrease in rate and depth of ventilation is an attempt to compensate by retaining carbon dioxide. The first response may be true, but it does not address all the components of the question. The third and fourth answers are inaccurate. The client has an order for hydrochlorothiazide (HCTZ) 10 mg orally every day. What should the nurse be sure to include in a teaching plan for this drug? Select all that apply. •"Take this medication in the morning." •"This medication should be taken in two divided doses when you get up and when you go to bed." •"Eat foods with extra sodium every day." •"Inform your prescriber if you notice weight gain or increased swelling." •"You should expect your urine output to increase." •"Your health care provider may also prescribe a potassium supplement." ✔✔•"Take this medication in the morning." •"Inform your prescriber if you notice weight gain or increased swelling." •"You should expect your urine output to increase." •"Your health care provider may also prescribe a potassium supplement."
The nurse is providing care for several clients who are at risk for acid-base imbalance. Which client is most at risk for respiratory acidosis? •A 68-year-old client with chronic emphysema •A 58-year-old client who uses antacids every day •A 48-year-old client with an anxiety disorder •A 28-year-old client with salicylate intoxication ✔✔•A 68-year-old client with chronic emphysema •Clients at greatest risk for acute acidosis are those with problems that impair breathing. Older adults with chronic health problems are at greater risk for developing acidosis. Whereas a client who misuses antacids is at risk for metabolic alkalosis, a client with anxiety is at risk for respiratory alkalosis. A client with salicylate intoxication is at risk for metabolic acidosis. The nurse is caring for a client who experiences frequent generalized tonic-clonic seizures associated with periods of apnea. The nurse must be alert for which acid-base imbalance? •Respiratory alkalosis •Respiratory acidosis •Metabolic alkalosis •Metabolic acidosis ✔✔•Metabolic acidosis •Seizures may be associated with apnea and thus hypoxemia and lactic acidosis. Lactic acidosis, a form of metabolic acidosis, occurs when cells use glucose without adequate oxygen (anaerobic metabolism); glucose then is incompletely broken down and forms lactic acid. This acid releases hydrogen ions, causing acidosis. Lactic acidosis occurs whenever the body has too little oxygen to meet metabolic oxygen demands (e.g., heavy exercise, seizure activity, reduced oxygen). The nurse is completing a history for an older client at risk for an acidosis imbalance. Which questions would the nurse be sure to ask? Select all that apply. •"Which drugs to you take on a daily basis?" •"Do you have any problems with breathing?" •"When was your last bowel movement?" •"Have you experienced any activity intolerance or fatigue in the past 24 hours?" •"Over the past month have you had any dizziness or tinnitus?" •"Do you have episodes of drowsiness or decreased alertness?" ✔✔•"Which drugs to you take on a daily basis?" •"Do you have any problems with breathing?" •"Have you experienced any activity intolerance or fatigue in the past 24 hours?" •"Do you have episodes of drowsiness or decreased alertness?" •Collect data about risk factors related to the development of acidosis. Older adults may be taking drugs that disrupt acid-base balance, especially diuretics and aspirin. Ask about specific risk factors, such as any type of breathing problem. Also ask about headaches, behavior changes, increased drowsiness,
reduced alertness, reduced attention span, lethargy, anorexia, abdominal distention, nausea or vomiting, muscle weakness, and increased fatigue. Ask the client to relate activities of the previous 24 hours to identify activity intolerance, behavior changes, and fatigue. Answers 3 and 5 are not common concerns with acidosis. Which specific instruction does the charge nurse give the unlicensed assistive personnel (UAP) helping to provide care for a client who is at risk for metabolic acidosis? •Check to see that the client keeps his oxygen in place at all times •Inform the nurse immediately if the client's respiratory rate and depth increases •Record any episodes of reflux or constipation •Keep the client's ice water pitcher filled at all times ✔✔•Inform the nurse immediately if the client's respiratory rate and depth increases •If acidosis is metabolic in origin, the rate and depth of breathing increase as the hydrogen ion level rises. Breaths are deep and rapid and not under voluntary control, a pattern called Kussmaul respiration. The client may not require oxygen. Although it's important to record reflux and constipation, this is not related to metabolic acidosis nor is keeping the water pitcher full specific to this condition.
