fundamentals [NCLEX Questions]
Terms in this set [15]
The RN cannot delegate checking the crash cart
Checking a crash cart is the responsibility of the licensed nurse, and, like any delegated task, the licensed nurse must consider the five rights of delegation prior to delegating the task. These five rights are: right task,
right circumstance, right person, right directions and communication, and right supervision and evaluation. Because checking a crash cart involves extensive auditing, charting of equipment, supplies, and medications, there is not a way to evaluate the performance of another person without going through and re-checking the entire thing. This task is too extensive and detailed to delegate.
Collecting a urine sample
This is the MOST non-invasive task. A
certified nursing assistant is qualified to assist the RN with many tasks. These can include helping with activities of daily living, including bathing, toileting, and ambulating clients. They may also take vital signs, count intake and output, and collect some lab specimens, such as for a urine sample. Remember, the five rights of delegation include the right task, right circumstances, right person, right direction/communication, and the right supervision.
1. 32 year old female receiving her first dose of Ancef 1g IVPB prior to surgery calls to complain of total body itching a rash and a 'funny' feeling on her tongue
---airway issue
2. 98 year old male in the bathroom yelling to be brought back into bed
---risk of falling
3. 22 year old male with insulin dependent diabetes requires his blood glucose checked prior to sliding scale insulin. Breakfast trays arrive at 0730.
---can hold the tray or have the UAP get
another RN
4. 56 year old female on call at 0730 for a cholecystectomy needs her pre-op meds and you find that her surgical consent form is missing.
---cannot get consent from the pt. after pre-op meds, secretary can help by calling the surgeon
5. The husband of an anxious S/P radical mastectomy patient is requesting pain meds for his wife.
--- pain is psychosocial so not as high priority-another RN can give pain meds , not enough information to be concerned about anxiety
6. Your favorite surgeon of all time is requesting assistance with a first time dressing change on a 36 year old female S/P colon resection.
---have the secretary call and ask to put it off to get it done, or have another RN do it
7. 78 year old female is watching television and cheering you on because she is a retired nurse and is just happy to know she is no longer in nursing.
---no concern at all
A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy?
Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by.
Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization.
Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself.
Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure.
Roles and responsibilities of PNs vary by state and facility practice. Most commonly, PNs are not able to provide IV treatments or perform assessments. PNs are qualified to give oral meds, perform client care activities, and collect vital signs.
A client is on neutropenic precautions. What role in client care would be appropriate for the practical nurse [PN]?
Administer 500 mg oral Vancomycin.
The PN is able to independently administer oral medications, help with
client care [bathing, walking, eating, oral hygiene, toileting], and collect vital signs.
NOT:
Give IV 40 mg pantoprazole.
All IV medications are administered by a registered nurse. Exceptions may exist where the PN acquires an IV certification.
Screen visitors for communicable diseases.
Screening visitors is a form of assessment, which must be reviewed by the registered nurse.
Determine which isolation precautions to initiate.
The registered nurse is responsible
for all assessments of the client, although the PN and the unlicensed assistive personnel may collect data for the nurse regarding the assessment. Ultimately, determining which isolation precautions to initiate is up to the registered nurse.
It is important for the RN to know and understand the scope of practice of the PN when delegating nursing actions to the PN. Complete assessments and formulation of nursing plans should be left to the RN to complete. PNs may auscultate breath sounds, use sterile technique to suction established tracheostomies, and administer ophthalmic medications.
A practical nurse [PN] and a registered nurse [RN] are assigned a group of clients on a nursing care unit. Which actions does the RN delegate to the PN?
Select All That Apply
Administer ophthalmic medications.
The practical nurse can administer ophthalmic medications using sterile technique.
Auscultate a client's breath sounds.
The PN may auscultate breath sounds and
record and report these findings. In-depth, head-to-toe assessments should be performed by the RN only.
Suction an established tracheostomy.
PNs may use sterile technique to suction an established tracheostomy. If the client is unstable or requires in-depth assessment, the RN performs this action.
NOT:
Complete a client's admission assessment.
The RN should perform the complete admission assessment because of its complex nature, and the implementation and initiation of the
nursing plan should be performed by the RN only.
Formulate the nursing care plan.
The PN can contribute to the nursing plan but cannot formulate a new nursing plan.
Delegation involves the registered nurse passing the responsibility of completion of a task another individual whose scope of practice includes the task. The nurse who delegated the task still remains accountable. The nurse first assesses and determines priority needs and determination of eligible staff for completion
of the task. In order to delegate, registered nurses need to be aware of Nurse Practice Acts in the location of practice and scope of practice for individuals to whom the nurse is delegating. The nursing process cannot be delegated.
Oxygenation is a priority issue as related to Maslow's hierarchy of needs and respiratory concerns. The client with oxygen needs requires immediate intervention. When a nurse is caring for a critical client, this client's needs should be addressed prior to the
needs of another client. If the nurse is unable to attend immediately to the oxygen needs of another client, it will be necessary to delegate to an appropriate caregiver so that the oxygen needs can be addressed.
A registered nurse provides care for a critically ill client and is unable to leave the client. A UAP obtains noon vital signs for another assigned client and reports the findings to the registered nurse. Which action does the nurse take? [See exhibit.]
Select All That
Apply
View Exhibits
Ask the PN to apply oxygen via nasal cannula at 2 L/min.
The registered nurse can delegate administration of oxygen to the practical nurses as this is within scope of practice.
NOT:
Report to the second client's room and apply supplemental oxygen.
The registered nurse should not leave the critical client, but should delegate management of the oxygen needs to another registered nurse or a practical nurse.
Ask the UAP to apply oxygen via nasal
cannula at 2 L/min.
Applying oxygen is not within the scope of practice for the unlicensed assistive personnel.
Complete care needs of current client, then assess second client's respiratory status.
The second client's oxygen needs should be addressed immediately and not left for after the RN is able to assess the client.
Report to the second client's room and assess respiratory status.
The registered nurse should not leave the critical client, but should delegate management
of the oxygen needs to another registered nurse or a practical nurse.
According the the NCLEX-PN test plan, PNs perform the following:
-Perform urinary catheterization
-Administer drugs by the PO, IM, and subcutaneous or intradermal route
-Give oxygen or other medications by inhalation, ear, eye, nose, or skin
-Administer drugs by gastrointestinal or nasogastric tube
-Monitor IV flow rate and may administer IV piggyback [secondary] medications
With required training, the PN can administer IV medications after the first dose has been administered by an RN. Any client expecting to receive IV medications should be managed by the RN. Stable clients are appropriate assignments for PNs, because they are generally on PO medications or IV medications that have been first administered by an RN. Newly admitted clients require an assessment and frequent monitoring from the RN until they are determined to be stable, so they are not appropriate assignments for care management by the PN.
A charge nurse assigns a practical nurse [PN] to six clients. The team includes a registered nurse [RN], a PN, and an unlicensed assistive personnel [UAP]. Which actions by the RN are correct?
Select All That Apply
Instruct the UAP to obtain vital signs on all assigned clients at 0800 and 1200.
It is within the scope of practice for UAP to obtain vital signs.
Inform the PN of the need to measure hourly output from the chest tube.
It is within
the scope of practice for the PN to measure chest tube output.
Instruct the PN to administer 0800 PO medications to all assigned clients.
It is within the scope of practice for the PN to administer PO medications.
NOT:
Ask the PN to complete an assessment on the client with a new chest tube.
It is the responsibility of the RN to complete an assessment on a client with a new admission or after a procedure.
Observe the PN administering newly ordered IV pain medication to
a client.
It is the responsibility of the RN to administer first doses of IV medications.
The RN must be mindful of appropriate delegation to various individuals working on the unit with the nurse. Assessment, planning, and evaluation should not be delegated to anyone other than the RN. Assistance with activities of daily living may be delegated to the UAP, not the PN. Observation of a client is within the scope of the PN and may be delegated as appropriate.
A registered nurse [RN] works with a practical nurse [PN] and unlicensed assistive personnel [UAP] to provide care for a client with emphysema and ineffective airway clearance. Which task is best assigned to the PN?
Observe the client's technique of airway clearance activities.
Observation is within the PN's scope of practice. This is an appropriate delegation.
NOT:
Assist the client with activities of daily living.
This action can be delegated to the UAP, not the PN.
Evaluate the
efficacy of the nursing care plan.
Planning and evaluating the nursing care plan should be performed by the RN, not the PN.
Assess the client's knowledge of airway clearance techniques.
PNs can gather data and report these findings, but assessment requires the advanced training of the RN. This action should not be delegated to the PN.
Delegation involves the RN passing the responsibility of completion of a task to another individual whose scope of practice includes the task.
The nurse who delegated the task still remains accountable. The nurse first assesses and determines priority needs and eligible staff for completion of the task.
In order to delegate, RNs need to be aware of Nurse Practice Acts in the location of practice and scope of practice for individuals to whom they are delegating. The nursing process cannot be delegated. Even though tasks may be delegated to other nursing personnel, the RN is still legally accountable for all nursing care tasks. The
registered nurse should never assume a delegated task has been completed. It is the RN's responsibility to ensure that care is given, so there must be follow-up after delegating a task.
A registered nurse [RN] delegates administration of a pain medication to a practical nurse [PN]. The client has surgical incision pain of 8/10. After completion of the task, which action does the RN take?
Follow up with the PN within 30 minutes of delegating this assigned task.
It is the
responsibility of the registered nurse to follow up to ensure the delegated task has been completed.
NOT:
Ask another nurse to verify administration of the medication by the PN.
Completion of the delegated task should be verified by the nurse delegating the task.
Document the administration of the pain medication in the client's health record.
The PN should document the medication administration when completed.
Supervise the PN while administering the medication.
It
is not necessary for the RN to supervise the PN while administering the medication.
Delegation involves the RN passing the responsibility of completion of a task to another individual whose scope of practice includes the task. The nurse who delegated the task still remains accountable. The nurse first assesses and determines priority needs and eligible staff for completion of the task. In order to delegate, RNs need to be aware of the scope of practice of individuals to whom they are delegating. The nursing process cannot be delegated.
A registered nurse [RN] receives a new admission who requires immediate and ongoing attention. The RN requests assistance for tasks with the remaining assigned clients. Which tasks require completion by an RN or a practical nurse [PN]?
Select All That Apply
Insertion of an indwelling urinary catheter for a client unable to void.
An indwelling urinary catheter should be placed by a PN or an RN.
Cleaning and suctioning
an endotracheal tube
This is a task that must be performed by a PN or RN.
Providing a client with instructions prior to discharge
Client education is completed by a nurse.
NOT:
Assisting a client with ambulation in the hallway
Unlicensed assistive personnel can assist a client with ambulation in the hallway.
Obtaining vital signs on a 1-day post appendectomy client
Unlicensed assistive personnel can obtain vital signs and report the findings to the nurse.
According
the the NCLEX-PN test plan, practical nurses perform the following:
1. Administer oral, IM, and subcutaneous medication
2. Perform urinary catheterization
3. Administer drugs by the PO, IM, and subcutaneous or intradermal route
4. Give oxygen or other medications by inhalation, ear, eye, nose, or skin
5. Administer drugs by gastrointestinal or nasogastric tube
6. Monitor intravenous [IV] flow rate and may administer IV piggyback [secondary] medications. With required training,
the PN can administer IV medications after the first dose has been administered by a registered nurse.
A registered nurse [RN] works with a practical nurse [PN] on a medical-surgical unit. Which tasks does the RN delegate to the PN?
Select All That Apply
Administer the first dose of ibuprofen 600 mg PO to a client for pain.
The practical nurse can administer PO medications.
Perform a urinary catheterization on a client unable to void.
A practical nurse can perform
urinary catheterization.
Administer the third dose of cefazolin 2 g by IV piggyback.
The practical nurse may administer IV piggyback [secondary] medications.
NOT:
Administer the first dose of ketorolac 30 mg IV to a post-surgical client.
The first dose of an IV medication must be administered by a registered nurse.
Initiate an IV infusion on a newly admitted client.
Initiation of an IV infusion must be performed by a registered nurse.
Unlicensed assistive personnel can perform many non-invasive tasks such as ambulation, activities of daily living, and the care of stable clients. Practical nurses [PNs] may do other invasive tasks, such as urinary catheter irrigation. PNs are not able to complete all tasks that registered nurses can, as they do not have the same knowledge base.When delegating, the nurse must follow the five rights of delegation: right task, right circumstance, right person, right direction and communication, and right supervision and evaluation. Responsibility always remains with the nurse as the licensed professional, even when tasks are delegated. Additionally, acts within the scope of practice for all healthcare providers may vary by state policy and should be the basis for delegation.
A nurse cares for a client with a prescription for irrigation of an indwelling urinary catheter. The nurse knows this task can be delegated to which personnel?
A practical nurse
Irrigation of a urinary catheter is within
the scope of practice for a practical nurse.
NOT:
The on-call urologist
It would not be appropriate to delegate this task to someone with higher training such as a urologist. This task can be performed by other qualified personnel.
An unlicensed assistive personnel
Unlicensed assistive personnel may not irrigate a catheter, as it is not within their scope of practice to do so.
A radiology technician
Irrigating an indwelling catheter must be done by a PN or RN, as
other personnel are not qualified to do such a procedure. A radiology technician does not have the necessary skills for this task.
According the the NCLEX-PN test plan, PNs perform the following:
1. Perform urinary catheterization
2. Administer drugs by the PO, IM, and subcutaneous or intradermal route
3. Give oxygen or other medications by inhalation, ear, eye, nose, or skin
4. Administer drugs by gastrointestinal or nasogastric tube
5. Monitor intravenous [IV] flow rate
and may administer IV piggyback [secondary] medications
With required training, the PN can administer IV medications after the first dose has been administered by a registered nurse. Any client expecting to receive IV medications should be managed by the RN. Stable patients are appropriate assignments for PNs, because they are generally on PO medications or IV medications that have been first administered by an RN. Newly admitted clients require an assessment from an RN and frequent monitoring until they are determined to be stable and, therefore, are not appropriate assignments for care management by a PN.
A charge nurse delegates assignments for the oncoming shift with a registered nurse [RN] and a practical nurse [PN]. Which assignments are appropriate for the PN?
Select All That Apply
A toddler-aged client 1-day post-surgical repair for clubfoot
This client can be appropriately managed by a PN as this is an established client and not a new admission
requiring assessment and frequent monitoring.
An adolescent client two days post-appendectomy
This client is stable and can be appropriately managed by the PN.
NOT:
A newly admitted adult client wth congestive heart failure
A newly admitted client requires assessment by an RN and, due to the diagnosis, requires frequent monitoring for the first few hours after admission.
An older adult client transferred from critical care after extubation
This is a new admission
and requires assessment and frequent monitoring by the RN for the first few hours after admission.
A young adult client with ovarian cancer admitted for chemotherapy
A client receiving chemotherapy should be assigned to an RN due to administration of IV chemotherapy and associated IV medications.
According to the NCLEX-PN test plan, PNs perform the following:
1. Urinary catheterization
2. Administration of drugs by the PO, IM, and subcutaneous or intradermal route
3.
Administration of oxygen or other medications by inhalation, ear, eye, nose, or skin
4. Administration of drugs by gastrointestinal or nasogastric tube
5. Monitoring IV flow rate and administering IV piggyback [secondary] medications
In some settings with required training, the PN can administer IV medications after the first dose has been administered by a registered nurse.
A registered nurse [RN] delegates care to a practical nurse [PN] on a medical-surgical unit. The nurse manager rounds on the unit. Which action observed being performed by the PN would require the nurse manager to discuss appropriate delegation with the RN?
Select All That Apply
Assessment of a newly admitted client from the surgical recovery room
Initial assessment of a newly admitted client must be completed by an RN.
NOT:
Administration of a first dose of IVPB cefazolin to a client with pneumonia
The PN can administer IVPB [secondary] medications.
Administration
of oxycodone, two tabs PO for post-surgical pain management
The PN can administer PO medications.
Changing the abdominal dressing of a client with a wound drain three days post-surgery
The PN can perform wound care such as dressing changes.
Removing the staples from a back surgical incision prior to discharge home
The PN can remove sutures or staples.