Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination Lacharity Chapters 1-21 (3rd Edition)

Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination Lacharity Chapters 1-21 (3rd Edition) Leave the first rating Students also studied Terms in this set (99) Science MedicineNursing Save Prioritization NCLEX questions 28 terms madisoncastello Preview Psychiatric Mental Health Nursing N...50 terms schwabaccaPreview ATI Med Surge Proctored Exam 202...135 terms briandagsanchez Preview Prioritiz 106 term hab As the charge nurse, you are reviewing the charts of clients who were assigned to the care of a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should you take first?

• Make a note in the nurse's file and continue to observe

clinical performance.

• Refer the new nurse to the in-service education

department.

• Quiz the nurse about knowledge of pain management

and pharmacology.

• Give praise for correctly charting the dose and time

and discuss the deficits in charting.Ans: 4 In supervision of the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making a note and watching do not help the nurse to correct the immediate problem. In-service training might be

considered if the problem persists. Focus: Supervision, delegation

Which clients must be assigned to an experienced RN?(Select all that apply.)

• Client who was in an automobile crash and sustained

multiple injuries

• Client with chronic back pain related to a workplace

injury

• Client who has returned from surgery and has a chest

tube in place

• Client with abdominal cramps related to food

poisoning

• Client with a severe headache of unknown origin
• Client with chest pain who has a history of

arteriosclerosis You have received the shift report from the night nurse.Prioritize the order in which you will check on the following clients.

• Adolescent who is alert and oriented. He was admitted
• days ago for

treatment of meningitis. He reports a continuous headache that is partially relieved by medication.

• Elderly man who underwent total knee replacement

surgery 2 days ago. He is using the patient-controlled analgesia (PCA) pump frequently with good relief and occasionally asks for bolus doses.

• Middle-aged woman who is demanding and needy.

She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning.

• Elderly woman with advanced Alzheimer disease who

requires total care for all activities of daily living (ADLs). She struggles during any type of nursing care and it is difficult to assess her subjective symptoms. She is awaiting transfer to a long-term care facili On the first day after surgery, a client receiving an analgesic via PCA pump reports that the pain control is inadequate. What is the first action you should take?

• Deliver the bolus dose per standing order.
• Contact the physician to increase the dose.
• Try nonpharmacologic comfort measures.
• Assess the pain for location, quality, and intensity.

Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader? Select all that apply.)

• Client who needs preoperative teaching for the use of a

PCA pump

• Client with a leg cast who needs neurologic and

circulatory checks and PRN hydrocodone

• Client who underwent a toe amputation and has

diabetic neuropathic pain

• Client with terminal cancer and severe pain who is

refusing medication

• Client who reports abdominal pain after being kicked,

punched, and beaten

• Client with arthritis who needs scheduled pain

medications and heat applications You are caring for a client who had abdominal surgery yesterday. The client is restless and anxious and tells you that the pain is getting worse despite the pain medication. Physical assessment findings include the

following: temperature, 100.3° F (38° C); pulse rate, 110

beats/min; respiratory rate, 24 breaths/min; and blood pressure, 140/90 mm Hg. The abdomen is rigid and tender to the touch. You decide to notify the client's provider. Place the following report information in the correct order according to the SBAR format.

1. "He is restless and anxious: temperature is 100.3° F (38°

C); pulse is 110 beats/min; respiratory rate is 24 breaths/min; blood pressure is 140/90 mm Hg. Abdomen is rigid and tender to touch with hypoactive bowel sounds."

• "He had abdominal surgery yesterday. He is on PCA

morphine, but he says the pain is getting progressively worse."

• "I have tried to make him comfortable and he is willi

Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation?(Select all that apply.)

• Anxious client with chronic pain who frequently uses

the call button

• Client on the second postoperative day who needs

pain medication before dressing changes

• Client with human immunodeficiency virus (HIV)

infection who reports headache and abdominal and pleuritic chest pain

• Client with chronic pain who is to be discharged with a

new surgically- implanted catheter

• Client who is reporting pain at the site of a peripheral

IV line

• Client with a kidney stone who needs frequent PRN

pain medication

A patient needs Klonopin 1 mg PO. The pharmacy delivers clonidine 0.1 mg tablets. A nursing student asks you if Klonopin and clonidine are two different names for the same drug. Place the following steps in the correct sequence so that you can teach the nursing student how ti prevent medication errors.

• Advise the pharmacy of any corrections as appropriate
• Recognize the "look-alike, sound-alike" drugs increase

the chances of error

• Consult a medication book to verify the purpose of the

drugs and generic and brand names

• Check the original medication order to verify what was

prescribed

• Write an incident report, as appropriate, if you believe

that a system error is occurring

• Call the MD for clarification of the order as appropriate
• Recognize the "look-alike, sound-alike" drugs increase the chances of error
• Check the original medication order to verify what was prescribed
• Consult a medication book to verify the purpose of the drugs and generic and

brand names

• Call the MD for clarification of the order as appropriate
• Advise the pharmacy of any corrections as appropriate
• Write an incident report, as appropriate, if you believe that a system error is

occurring Several patients are taking antipsychotic medications and are having medication side effects. Place the following patients in priority order for additional assessment and appropriate interventions.

• A patina who is taking trifluoperazine and has a

temperature of 103.6 with tachycardia, muscular rigidity, and dysphagia

• A patient who is taking fluphenazine and has dry mouth

and dry eyes, urinary hesitancy, constipation, and photosensitivity

• A patient who is taking loxapine and has a protruding

tongue with lip smacking and spastic facial distortions

• A patient who is taking clozapine and reports a sore

throat, fever, malaise, and flulike symptoms that began about 6 weeks ago after starting the new antipsychotic medication; WBC is 2000

• A patient who is taking loxapine and has a protruding tongue with lip smacking

and spastic facial distortions

• A patina who is taking trifluoperazine and has a temperature of 103.6 with

tachycardia, muscular rigidity, and dysphagia

• A patient who is taking clozapine and reports a sore throat, fever, malaise, and

flulike symptoms that began about 6 weeks ago after starting the new antipsychotic medication; WBC is 2000

• A patient who is taking fluphenazine and has dry mouth and dry eyes, urinary

hesitancy, constipation, and photosensitivity You are reviewing the principle of "least restrictive" intervention with the staff. Place the following intervention in the correct ascending order from the least restrictive to the most restrictive.

• Escort the patient to a quite room for a time out
• Restrain the patient's arms and legs with soft cloth

restraints

• Verbally instruct the patient to stop the unacceptable

behavior and move to another part of the day room

• Accompany the patient out into the garden courtyard
• Restrain the patient's upper extremities with wrist

restraints

• Place the patient in an isolation room with a mental

health assistant observing

• Verbally instruct the patient to stop the unacceptable behavior and move to

another part of the day room

• Accompany the patient out into the garden courtyard
• Escort the patient to a quite room for a time out
• Place the patient in an isolation room with a mental health assistant observing
• Restrain the patient's upper extremities with wrist restraints
• Restrain the patient's arms and legs with soft clothrestraints