Fundamental Final

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Questions and Answers

What must be demonstrated to establish a claim of malpractice?

The client must have consented to the treatment.

A relationship must exist between the client and the healthcare provider.

Four key elements must be proven: duty, breach of duty, injury, and proximate cause. (correct)

The healthcare provider must be licensed in the state where the treatment was administered.

Which of the following rights does a client NOT have?

Right to unlimited access to all patient records (correct)

Right to adequate and competent care

Right to confidential information

Right to refuse treatment

When delegating tasks, what is NOT a consideration for a registered nurse?

The educational background of the unlicensed assistive personnel.

The predictability of outcome associated with the task.

The nurse's personal opinion on the task. (correct)

The potential for harm resulting from the task.

What effect does digoxin primarily have on the heart?

It decreases conduction speed and reduces heart rate. Signup and view all the answers

What is the maximum flow rate for a nasal cannula?

6 liters Signup and view all the answers

What is a common adverse effect of nitrates?

Headache Signup and view all the answers

Which type of face mask provides the most precise oxygen delivery?

Venturi mask Signup and view all the answers

What is a key precaution when using an oxygen tent?

Ensure the canopy encloses the patient's upper torso Signup and view all the answers

Which symptom is most indicative of oxygen toxicity?

Persistent headache Signup and view all the answers

What should be done when a reservoir of a face mask completely collapses?

Turn up the oxygen as per doctor's order Signup and view all the answers

In what scenario should you apply a mask firmly to the patient's face when using an Ambu bag?

When delivering breath every 5 seconds Signup and view all the answers

What is the primary method of preventing pathogen transmission?

Practicing handwashing before and after client contact Signup and view all the answers

What is the purpose of using the RACE acronym in safety protocols?

To respond effectively to fires Signup and view all the answers

What should you do if a specimen is collected incorrectly?

Start the collection process over Signup and view all the answers

What should be monitored closely in patients at risk for infection?

Their signs and symptoms of distress Signup and view all the answers

Which of the following is a recommended preparation for triglyceride testing?

No alcohol for 24 hours Signup and view all the answers

What is the normal range for blood urea nitrogen (BUN) levels?

10-20 mg/dl Signup and view all the answers

What is the significance of HDL levels in relation to heart disease?

Lower levels correlate with higher risk Signup and view all the answers

Which method is used for wound debridement according to the provided practices?

Applying wet dressing and allowing it to dry Signup and view all the answers

What should be done with the wetting solutions after wound care?

Discard after 24 hours Signup and view all the answers

What is the recommended position for a patient during a tracheostomy procedure?

Semi-Fowler’s position Signup and view all the answers

What is the normal potassium range in mEq/L?

3.5-5.0 mEq/L Signup and view all the answers

Which factor is likely to elevate triglyceride test results?

Consuming high-fat meals within 2 weeks prior Signup and view all the answers

When performing suctioning, how should the suctioning process be conducted?

Suction only when coming out Signup and view all the answers

What is the critical level for triglycerides that necessitates immediate attention?

<blockquote> 400 mg/dl </blockquote> Signup and view all the answers

What should be done to the inner cannula of a tracheostomy tube after cleaning with peroxide?

Rinse with sterile saline Signup and view all the answers

What is the maximum temperature that should be used for enemas?

105 degrees Fahrenheit Signup and view all the answers

Which of the following statements about sodium levels is true?

Sodium levels between 135-145 mEq/L are normal Signup and view all the answers

Which of the following statements about catheter care is correct?

Empty the drainage bag at the end of the shift Signup and view all the answers

Why is gentle washing with a stream of solution important in wound care?

To prevent further tissue damage and reduce infection risk Signup and view all the answers

Which fluid is most commonly used in irrigation procedures?

Isotonic solution Signup and view all the answers

What is crucial to do before and after any sterile procedure?

Use PPE Signup and view all the answers

In a 24-hour urine collection, what should the patient do at the start and end of the collection period?

Discard the first specimen and keep the last Signup and view all the answers

What is the proper technique when changing tracheostomy ties?

Change one side of the cotton tie at a time Signup and view all the answers

What must be done to assess for bladder distention after catheter removal?

Palpate the abdomen immediately Signup and view all the answers

Which type of wound healing involves the edges of the wound being brought together?

Primary intention Signup and view all the answers

What is the appropriate frequency for checking a client in restraints?

Every 15-30 minutes Signup and view all the answers

Which of the following is a priority action before using a patient lift?

Lock the wheels Signup and view all the answers

What should you do if a client in restraints shows signs of distress?

Assess their mental function Signup and view all the answers

Which of the following substances must be strictly avoided around oxygen due to flammability?

Grease Signup and view all the answers

What is the recommended setting for long-term oxygen therapy in patients with chronic respiratory illnesses?

1-2 L/min Signup and view all the answers

Which type of oxygen delivery method typically requires humidification for long-term use?

Low-flow oxygen Signup and view all the answers

Oxygen flow rate is typically ordered in which unit of measurement?

Liters per minute Signup and view all the answers

What is the primary distinction between primary and secondary intention in wound healing?

Primary intention heals with minimal scarring. Signup and view all the answers

When using physical restraints, which is NOT a recommended practice?

Secure the restraints tightly to prevent movement. Signup and view all the answers

What action should be taken every 2 hours for a client in restraints?

Assist the client with toileting and exercise. Signup and view all the answers

What is the most important factor to consider when using an oxygen delivery system?

The compatible oxygen flow rate for the patient’s condition. Signup and view all the answers

Which gas is characterized as odorless, tasteless, and non-flammable yet supports combustion?

Oxygen Signup and view all the answers

What critical precaution should be taken concerning the use of an oxygen delivery system?

Ensure the presence of no smoking signs. Signup and view all the answers

What is required before using a patient lift to assist with client movement?

Lock the wheels of the lift. Signup and view all the answers

Which of the following practices is essential for maintaining oxygen equipment?

Checking and adjusting the flow meter regularly. Signup and view all the answers

What is the primary focus when monitoring a patient for pain management with narcotics?

Always assess pain before and after medication Signup and view all the answers

Which of the following statements about documentation in nursing practice is accurate?

Use factual information only when documenting unusual events Signup and view all the answers

In the context of preparing for medication administration, which route would likely have the fastest absorption?

Sublingual (SL) Signup and view all the answers

Which scenario best illustrates the definition of assault in a healthcare setting?

A doctor threatens to delay treatment unless a patient complies with orders Signup and view all the answers

When assessing for skin breakdown during bathing, which practice should a caregiver predominantly follow?

Rinse all soap thoroughly and dry by patting Signup and view all the answers

What is the correct sequence of actions when performing a sterile procedure?

Protect self, wash hands, irrigate, perform suctioning. Signup and view all the answers

When collecting a 24-hour urine specimen, what is an important initial step?

Discard the first void and begin collection after. Signup and view all the answers

What is the maximum height at which irrigation should be performed, according to safe practice guidelines?

18 inches. Signup and view all the answers

What should be done with the inner cannula of a tracheostomy tube after it is cleaned?

Rinse with sterile saline after cleaning. Signup and view all the answers

How often should an indwelling urinary catheter be changed?

Every month. Signup and view all the answers

What position should a patient be placed in for optimal comfort during irrigation procedures?

Left Sim's position. Signup and view all the answers

What is a critical step during the changing of tracheostomy ties?

Remove only one side at a time while stabilizing the tube. Signup and view all the answers

What should be monitored after suctioning a patient?

Lung sounds and respiratory status. Signup and view all the answers

What is the appropriate action if there is no output detected in an indwelling urinary catheter after its removal?

Assess for bladder distention. Signup and view all the answers

Which of the following practices is NOT recommended during the use of a syringe for irrigation?

Injecting solution directly into the most contaminated area. Signup and view all the answers

What is the maximum oxygen concentration delivered by a simple face mask?

60% Signup and view all the answers

Which intervention is essential for a patient receiving oxygen via a nasal cannula?

Document the oxygen type as BNC or BNP. Signup and view all the answers

In which situation should the oxygen flow rate in an oxygen tent be adjusted?

If the patient shows signs of respiratory distress. Signup and view all the answers

What is a potential symptom of oxygen toxicity?

Fatigue. Signup and view all the answers

What is the appropriate action if a non-rebreather mask’s reservoir bag fully collapses?

Increase the oxygen flow rate per doctor's order. Signup and view all the answers

What is an important safety consideration when using the hyperbaric chamber?

Monitor for signs of hypoxia inside the chamber. Signup and view all the answers

Which procedural preparation is necessary for performing an intravenous pyelogram (IVP)?

Ensure the patient is NPO after midnight. Signup and view all the answers

What technique should be used for urine specimen collection for a culture and sensitivity test?

Collect mid-stream after cleaning the area. Signup and view all the answers

What is a critical step during the process of venipuncture?

Release the tourniquet before needle removal. Signup and view all the answers

Which of the following is a correct principle of sterile techniques?

Only sterile items can touch other sterile items. Signup and view all the answers

Which of the following substances is critical for management of severe hypoglycemia?

Glucagon administered SC, IM or IV Signup and view all the answers

What is the normal range for triglyceride levels in adults?

40-160 mg/dl Signup and view all the answers

Elevations in blood urea nitrogen (BUN) levels can indicate which of the following conditions?

Dehydration and kidney impairment Signup and view all the answers

What is the normal value range for sodium levels in mEq/L?

135-145 Signup and view all the answers

Which of the following is a primary risk factor for heart disease related to low-density lipoprotein (LDL) levels?

Levels exceeding 180 mg/dl Signup and view all the answers

What is the recommended fasting duration prior to testing triglyceride levels?

12-14 hours Signup and view all the answers

Which method is employed for effective wound debridement?

Using wet dressings and allowing them to dry Signup and view all the answers

What can significantly elevate triglyceride test findings in patients?

Alcohol consumption 24 hours before the test Signup and view all the answers

What is the normal value range for serum potassium levels?

3.5-5.0 mEq/L Signup and view all the answers

Which of the following statements about wound culture collection is accurate?

Old drainage should be removed before collecting the culture. Signup and view all the answers

When monitoring a patient using oxygen therapy, how often should oxygen saturation be checked?

Every four hours Signup and view all the answers

What must be done every two hours for a patient in restraints?

Release, toilet, and exercise restraints Signup and view all the answers

Which face mask type delivers the highest concentration of oxygen?

Non-rebreather mask Signup and view all the answers

What is the critical consideration before applying restraints to a patient?

Obtaining consent Signup and view all the answers

In what scenario should a transfer belt be secured?

On the patient's stronger side Signup and view all the answers

What is the critical level for total cholesterol that would necessitate immediate attention?

≥ 300 mg/dl Signup and view all the answers

Which factor is NOT considered when delegating a nursing task?

Your own comfort level Signup and view all the answers

What is the normal range for potassium levels in mEq/L?

3.5 - 5.0 mEq/L Signup and view all the answers

What is the necessary procedure for a midstream urine collection?

Void a little, then collect into a cup Signup and view all the answers

What is the maximum height the enema bag should be positioned above the patient?

18 inches Signup and view all the answers

Which statement about wound irrigation is true?

Normal saline is an isotonic solution commonly used for irrigation. Signup and view all the answers

What is the recommended patient position during gastroesophageal feeding?

Sitting upright position Signup and view all the answers

What is the most critical precaution to take when using a hyperbaric chamber for oxygen therapy?

Monitor for oxygen toxicity symptoms frequently. Signup and view all the answers

Which statement correctly describes the handling of an Ambu bag during resuscitation?

Breaths should be delivered every 5 seconds consistently. Signup and view all the answers

What is a major risk for patients receiving oxygen concentrations over 50% for an extended period?

Oxygen toxicity resulting in respiratory distress. Signup and view all the answers

Which of the following conditions is a sign of oxygen toxicity?

Non-productive cough and fatigue. Signup and view all the answers

What is an essential action to take before performing an intravenous pyelogram (IVP)?

Assess for allergies to iodine contrast dye. Signup and view all the answers

Which method is most effective for collecting a sterile urine sample?

Catheterization for direct access to the bladder. Signup and view all the answers

What should be monitored closely post-arteriogram?

The injection site for evidence of bleeding. Signup and view all the answers

Which safety precaution should always be followed regarding fire safety when dealing with oxygen delivery?

Avoid using electrical equipment in the vicinity. Signup and view all the answers

Study Notes

Restraints

Restraints are only used with a doctor's order, and should be the least restrictive option.
Restraints are not a first-line intervention.
Check restraints every 15 - 30 minutes.
Release, toilet, and exercise restraints every 2 hours.
Obtain consent before applying restraints.
Check circulation distal to restraints.
Patients may refuse restraints, so assess mental function and notify the physician and the responsible party. Document the refusal.

Patient Lifts

Always lock the lift before use.
Ensure the base of the lift is spread before use.
Place the patient in the center of the sling.
Reassure your patient and get training and assistance; do not use this alone.

Transfer Belt

Lock the wheels on the transfer belt.
Place the transfer belt closest to the patient's stronger side.
Do not secure any tubing to movable parts.

Oxygen Therapy

Oxygen is odorless, colorless, tasteless, non-flammable but supports combustion.
The flow meter regulates the rate of oxygen flow, and Fi02 is the percentage of oxygen concentration.
Oxygen is usually ordered in Liters/Minute.
Chronic respiratory illnesses will require lower settings of oxygen delivery (usually no more than 1-2 L/M).
Long-term oxygen use requires humidification.
"No SMOKING" signs should be in place and enforced.
Know the location of fire extinguishers.
Avoid using grease, oil, vaseline, alcohol, ether or ungrounded equipment near oxygen.
Monitor breath sounds every shift, and oxygen saturation every 4 hours.

Nasal Cannula

Also known as BNP or BNC.
Fits in the patient's nares.
Can deliver a concentration of 24-44%.
No more than 6 liters should be administered.
Turn on oxygen before placing the cannula on the patient.
Tubing goes over the ears, and you may want to pad this area.
Provide nares care, including assessment of the skin.
Use water-soluble lubricant.

Face Mask

Allows more control over low oxygen levels.
Can deliver an oxygen concentration of 60-100% (6-10 liters)- dependent on the Liter/Minute.
A fine mist should be seen with humidified oxygen.
Adjust the mask so that it fits snugly over the nose and covers the chin.
The reservoir should never completely collapse. If it does, the oxygen should be turned up per the physician's order.
There are different types of masks:
- Venturi (4-10L/24-55%): Delivers precise amounts of oxygen.
- Non-rebreather (6-15L/up to 100%): Delivers the highest concentration of oxygen.
- Simple (5-8L/35-55%): Delivers a lower concentration of oxygen.

### Oxygen Tent

Deliveres a fine mist, constant temperature, and high concentration of oxygen to the patient.
The canopy must fully enclose the upper torso of the patient.
Keep the patient dry and prevent chilling, changing linens more frequently.
The temperature inside the canopy should be 70 degrees.
Adjust the oxygen flow rate to 10-12 L/M
Tuck the sides of the canopy under the mattress.
A parent or guardian may need to get under the tent to keep their child inside.

### Hyperbaric Chamber

Delivers 100% oxygen at 3 times atmospheric pressure.
Helps regenerate new tissue at a faster rate.

### Ambu Bag

Delivers up to 100% concentration depending on the presence of a reservoir.
The mask must firmly cover the mouth and nose to form a seal.
A breath should be delivered every 5 seconds using the Ambu bag.
The Ambu bag can be attached to an endotracheal tube (ET tube).

### Oxygen Toxicity

Seen more often when administering oxygen concentrations over 50% for longer than 24-48 hours.
Symptoms include:
- Non-productive cough
- Substernal chest pain
- Nasal stuffiness
- Nausea and vomiting
- Fatigue
- Headache
- Sore throat
- Hypoventilation

### Oxygen Safety

Encourage good oral hygiene.
Encourage the patient to force fluids.
Use TCDB (Turning, Coughing, Deep Breathing).
Provide humidification.

Fire Safety

Remember RACE (Rescue-Alarm-Contain-Extinguish)
Use PASS (Pull-Aim-Squeeze-Sweep)

Home Safety

Monitor those at risk more closely.
Use call lights, brakes, and side rails appropriately.
Teach home safety, including:
- Grab bars
- Avoid use of rugs
- Keep floors clutter free
- Night lights

Infection Control

Handwashing is the most important way to prevent transmission of pathogens; wash before and after patient contact.
Isolation precautions depend on how the pathogen is spread; know the guidelines.

Cycle of Infection

The cycle of infection includes:
- Pathogen
- Reservoir
- Portal of exit
- Mode of transmission
- Portal of entry
- Host

Sterile Technique

Sterile to sterile only.
When in doubt, it is contaminated.
Review sterile techniques.

Documentation

Documentation should be:
- Factual
- Subjective
- Objective
Follow these rules of charting:
- Accurate, concise, and pertinent
- Complete and current
- Organized and timely
- Use only symbols/abbreviations approved by the facility
- Correct spelling, using proper English
- Focus on the patient and their condition
- Use good penmanship and correct punctuation
- Always use ink.
- Never use whiteout.
- When making a mistake, draw a single line through it and write "error."

Communication

Communication includes verbal—spoken, written, and nonverbal.
Look for congruency between verbal and nonverbal communication.
Avoid false hope or clichés.
Acknowledge the patient's feelings and concerns.
When communicating with special situations, remember to:
- Approach confused/agitated patients calmly and slowly.
- Don't sneak up on blind patients.
- Don't raise your voice with hearing-impaired patients; face them when talking, speak clearly and distinctly.

Non-invasive Diagnostic Tests

No special preparation is needed for non-invasive tests.
No consent form is required.
Examples include: CXR, hand, ankle, leg X-ray.

Biopsy

Requires a consent form.
A CBC may be needed before the test.
Local anesthetic will be used.
The iliac crest is the most common site.
Apply pressure dressing; monitor for bleeding and signs of shock.
Expect some tenderness at the site.

### Intravenous Pyelogram (IVP)

Investigates the kidneys.
Check for allergies to iodine.
Perform before any barium studies.
The patient should be NPO after midnight.
A laxative may be required pre-test.
Encourage the patient to force fluids post-test.
Consent is usually obtained by radiology.
Respiratory difficulties after dye injection may indicate an anaphylactic reaction.

### Arteriogram

Requires consent.
Assess allergies to contrast dye.
Keep the patient flat for 8 hours after the test with the extremity extended.
Encourage fluids post-test.
Monitor the insertion site for bleeding.
Do not remove pressure from the site.
Assess under the extremity for bleeding.
Other contrast media tests include:
- Renal arteriogram
- Lung scan
- Femoral angiogram

### Venipuncture

Explain the procedure to the patient.
Protect yourself using PPE.
Get assistance when needed.
Be sure to clean the skin appropriately.
Ensure you have the correct collection tube and order of draw.
Release the tourniquet before removing the venipuncture needle.
Apply pressure to the site post-test.

Endoscopic Procedures

Requires consent.
Endoscopes are lighted instruments used to visually examine internal structures.
The patient should be NPO after midnight.
Bowel prep is needed for colonoscopy.
The patient should be NPO after midnight; nothing by mouth after the procedure until gag and swallowing reflexes return. Monitor the patient for the return of these reflexes.
Vital signs should be monitored every 30 minutes until stable post procedure.
Monitor for respiratory distress after a bronchoscopy.
Monitor for bleeding if polyps are removed during a colonoscopy.

Specimen Collection

Do not touch the inside of the container.
Label the container, not the top.
Midstream urine collection: Clean, void a little, then collect urine.
Sterile urine collection: The only sterile method is to catheterize.
- Foley Catheter: Use alcohol to clean the port before collecting urine with a syringe.
When collecting a culture and sensitivity specimen and antibiotics are ordered, collect the specimen first.
24-hour urine collection: Discard the initial void; keep the last void and every amount in between. Keep the collection on ice; if any amount is lost, start over.

Blood Glucose

Orange juice, hard candy, honey, commercial glucose, glucagon via SC, IM, IV, or glucose 10% or 50% IV can be used to treat hypoglycemia.

### Uric Acid

No special preparation is required.
Elevated levels are seen in gout.
Normal value is 3.0-7.0 mg/dl.

### Creatinine

Investigates kidney function.
Elevated levels are seen in kidney failure.
Normal level is 0.6-1.2 mg/dl.

### BUN

Blood Urea Nitrogen
Investigates kidney function.
Elevated levels are seen in dehydration or kidney impairment.
Normal level is 10-20 mg/dl.

### Electrolytes

Potassium: 3.5 - 5.0 mEq/L
Sodium: 135-145 mEq/L

### Triglycerides

The patient should be NPO for 12-14 hours prior to the test.
Avoid alcohol for 24 hours prior to the test.
High-fat ingestion up to 2 weeks prior to the test may elevate results.
Normal values:
- Male: 40-160 mg/dl
- Female: 35-135 mg/dl
A level greater than 400 mg/dl is critical.

### Cholesterol

HDL (High-Density Lipoprotein): 30-80 mg/dl. Lower levels indicate an increased risk of heart disease.
LDL (Low-Density Lipoprotein): 60-180 mg/dl.
VLDL (Very Low-Density Lipoprotein): 25-50%.
The patient should be NPO prior to testing.
Smoking and alcohol can elevate values.

### Total Cholesterol

The patient should fast for 12-14 hours before the test, while following a low-fat diet.
Avoid alcohol for 24 hours prior to the test
Normal values:
- Adult/Elderly: < 200 mg/dl

Wound Care

Wet-to-Dry Dressings:
- Apply wet.
- Allow to dry.
- Used for wound debridement.
- Sterile procedure.
- Discard wetting solutions after 24 hours.
- Cleanse the wound prior to applying a new dressing.
- Document the condition of the wound and any drainage or odor.

### Wound Culture

Collect a culture after cleansing any old drainage from the wound.
Use a sterile swab stick or syringe.

Wound Irrigation

Gentle washing of an area with a stream of solution through an irrigating syringe to prevent further tissue damage and introduction of bacteria.
Promotes wound healing and comfort.
Method of cleansing wounds and administering medication
Most commonly used solution: Normal Saline (isotonic solution)
Irrigation Principles:
- Irrigating solution flows from least contaminated to most contaminated areas.
- Cleanse the wound from least contaminated to most contaminated areas.
Wash hands before and after irrigation.
Protect yourself (PPE).
Use either a syringe alone, or a syringe with an IV catheter or needle.
Use a collection device to catch the irrigation fluid.

Tracheostomy Care

Suction before cleaning.
Sterile procedure.
Do not remove the outer cannula.
Place the patient in a semi-Fowler's position.
Never remove the outer cannula, only the inner cannula.
Rinse the inner cannula with sterile saline after cleaning with hydrogen peroxide.
When changing ties, remove only one side of the cotton tie at a time, keeping the tracheostomy tube stabilized.
Tie at the side of the neck.
Auscultate lung sounds after cleaning.
Good oral hygiene is important.

### Suctioning

Nasopharyngeal/Tracheal suctioning is sterile.
Oropharyngeal suctioning is clean.
Suction only on the way out.
Assess respiratory status before and after suctioning.

Urinary Catheterization (Foley Catheter)

Sterile procedure.
Insert the catheter past the point of urine.
Inflate the balloon.
Do not kink the tubing.
Do not allow dependent loops in the tubing.
Do not allow the client to lie on the tubing.
Do not allow the drainage bag to go above the bladder.
Use the port to collect a urine specimen using a needle/syringe.
Empty the bag at the end of each shift.
Assess for bladder distention when there is no output from the catheter or after its removal.
Use a larger bag at night.
The catheter should be changed every month.

Urine Collections

24-hour urine collection:
- Collect all urine within the 24-hour period.
- Keep the collection on ice.
- Have the patient empty their bladder at the beginning and discard the sample. Have them empty their bladder and save the sample at the end of the collection period.
Midstream urine collection: Clean, void a little, and then collect the sample into a cup.
Indwelling Urinary Catheter:
- Use alcohol to clean the port.
- Use a needle/syringe to collect the urine.
- Clamp the tubing for no longer than thirty minutes to collect urine.
Specific Gravity: 1.000 to 1.030

### Enemas

Clean procedure..
Types:
- Fleet
- Retention
- SSE
- TWE
- Carminative
Steps:
- Left Sim's position
- Water temperature should be no higher than 105 degrees.
- Do not add soap until the water is in the enema bag
- The enema bag height should be no more than 18 inches above the patient.
- Generally, no more than 3 buckets without a physician's order.
Review the appropriate enema procedure.

### Gastrostomy Feeding

Upright position for feeding.
Always check placement and residual, following physician orders.

### Client Rights

Patient rights:
- Right to Information: Inform the patient of his/her condition, treatment options and plan of care.
- Right to Refuse Treatment: -Right to Adequate, Competent Care:
- Right to Have their Bill Explained:
- Right to Confidentiality:

### Delegation

Delegation: Transferring the authority to perform selected nursing tasks in a selected situation to a competent individual.
Accountability: Being responsible and answerable for actions or inactions of self or others in the context of the delegation process.
Unlicensed Assistive Personnel (UAP): Any unlicensed personnel to whom nursing tasks are delegated.
Supervision: Provision of guidance or direction, evaluation, and follow-up by a licensed nurse for the completion of assigned tasks delegated to a UAP.

### Delegation Principles

Right Task: Is the task appropriate for delegation?
Right Circumstances: Is this the right time and setting to delegate?
Right Person: Is the person the right person to take on this task?
Right Direction/Communication: Are the instructions clear and concise?
Right Supervision/Evaluation: Is the RN properly supervising and evaluating the task?

### Delegation Considerations

RNs can delegate to other RNs, LPNs and APs.
LPNs can delegate to other LPNs and APs.
Only delegate tasks appropriate for the skill and education level of the nurse receiving the assignment.
RNs cannot delegate the nursing process, patient education, or tasks that require nursing judgment to LPNs or APs.

### 5 Rights of Delegation

Predictability of outcome: Is the task routine, and can its outcome be predicted?
Potential for harm: What is the risk of harm to the patient if the task is not performed correctly?
Complexity of care: How many steps does the task require? Must clinical judgment be used?
Need for problem solving and innovation: Can the UAP solve problems or make changes if they arise while performing the task?
Level of interaction with the client: Does the task require specialized interaction and judgment?

### Competency

Factors To Consider:
- Education, training, and experience.
- Knowledge and skill.
- Level of critical thinking required to complete the task.
- Ability to communicate effectively.
- Demonstrated competence.
- Facility policies and procedures.
- Licensing legislation (nurse practice acts).

### Cardiac Medications:

Cardiac Glycosides:
- Action: Increase cardiac output, slow HR, decrease conduction.
- Uses: Heart failure, atrial fibrillation.
Adverse Effects: Headache, weakness, drowsiness, visual disturbances, arrhythmias, GI upset, anorexia.
Toxicity:
- Lanoxin (digoxin): Loading dose. Therapeutic drug level is 0.8-2.0 ng/mL.
- Toxicity symptoms include green/yellow visual disturbances, anorexia, nausea, vomiting, changes in cardiac function.
- Monitor potassium levels: Hypokalemia predisposes to digoxin toxicity.
- Antidote: Digibind (digoxin immune)
- Primacor (milrinone lactate); IV only.

### Vasodilators

Relax smooth muscles (vessels), increasing blood flow to the heart.
Nitrates:
- Uses: Relieve pain associated with angina, prevent anginal attacks, treat chronic, stable angina.
- Adverse Effects: Headache, dizziness, weakness, hypotension, flushing.
- Examples: ISMO, Imdur (isosorbide mononitrate); Isordil (isosorbide dinitrate); Nitro-Bid, Nitrostat (nitroglycerin).
Calcium Channel Blockers:
- Action: Slow conduction, dilate coronary arteries, depress contractility of the heart.
- Uses: Angina, hypertension.
- Adverse Effects: Dizziness, lightheadedness, fatigue, nausea, constipation, peripheral edema, hypotension, bradycardia, nasal congestion, cough.
- Examples: Norvasc (amlodipine); Cardizem (diltiazem HCL); Plendil (felodipine); Cardene (nicardipine HCL); Procardia, Adalat (nifedipine); Calan, Isoptin (verapamil HCL).

### Nitroglycerin Administration

Give sublingual nitroglycerin 1 tablet every 5 minutes x 3. If the pain is still present after 3 tablets, call the physician.
Monitor vital signs, including taking an apical pulse.
Protect patient safety.
Monitor and document chest pain.

### Nitroglycerin Safety

Get a new bottle every 3 months.
Keep nitroglycerin in a brown bottle.
Rise slowly from a lying or sitting position.
Nitroglycerin should tingle or sting when used.
Rotate patch sites, removing the old patch.
Keep nitroglycerin with you at all times.

Antihypertensive Medications

Uses:
- Hypertension.
- Hypertensive Emergencies.
- Diagnosis of pheochromocytoma (alpha-adrenergic blocking drugs).

### Antihypertensive Drug Classes

Peripheral Vasodilators:
- Adverse Effects: Hypotension, dizziness, angina, headache, hirsuitism, nasal congestion, fatigue, sodium and water retention.
- Examples: Apresoline (hydralazine HCL); Loniten (minoxidil).
Beta Blockers:
- Adverse Effects: CHF, dizziness, bradycardia, arrhythmias, decreased libido, impotence, constipation/diarrhea.
- Examples: Tenormin (atenolol); Lopressor, Toprol (metoprolol); Corgard (nadolol); Inderal (propanolol); Blocadren (timolol maleate).
Antiadrenergic Drugs (Centrally Acting):
- Adverse Effects: Drowsiness, sedation, headache, dry mouth, hypotension, syncope, fluid retention, constipation.
- Examples: Catapres (clonidine HCL); Tenex (guanabenz acetate); Aldomet (methyldopa).
Antriadrenergic Drugs (Peripherally Acting):
- Adverse Effects: Headache, fatigue, hypotension, lethargy, dyspepsia, headache.
- Examples: Cardura (doxazosin); Ismelin (guanethidine monosulfate).
Alpha-Adrenergic Blockers:
- Adverse Effects: Headache, fatigue, hypotension, sexual dysfunction, lack of energy
- Examples: Regitine (phentolamine).
ACE Inhibitors: (pril drugs)
- Adverse Effects: Nausea, cough, hypotension, headache, fatigue.
- Examples: Lotensin (benazepril HCL); Capoten (captopril); Vasotec (enalapril); Mavik (trandolapril); Zestril (lisinopril)
Angiotensin II Receptor Antagonists (sartan drugs):
- Adverse Effects: Diarrhea, abdominal pain, hypotension, fatigue, headache, lightheadedness, URI symptoms, cough.
- Examples: Atacand (candesartan cilexetil); Avapro (irbesartan); Cozaar (losartan potassium); Micardis (telmisartan); Diovan (valsartan).
Hypertensive Emergency Drugs:
- Adverse Effects: Dizziness, weakness, nausea/vomiting, sodium and water retention, apprehension, headache.
- Examples: Hyperstat (diazoxide); Nitropress (nitroprusside sodium);

### Antihypertensive Nursing Considerations

Take the blood pressure before administering the medication.
Monitor for adverse effects.
Monitor intake and output.
Dangle the patient's legs before getting out of bed to prevent orthostatic hypotension.

### Antihypertensive Patient Teaching

Do not stop medications abruptly.
Report any adverse effects to the physician.
Take medications as directed.
Attend follow-up appointments.
Report any signs and symptoms of heart failure (sudden weight gain, swelling, shortness of breath) to the physician.
Do not use OTC cold preparations without clearing it with the physician.

Assault and Battery

Assault involves intentional threat to cause bodily harm to another
Battery involves unlawful touching of another person without informed consent

Defamation

Slander involves untrue spoken words about another person
Libel involves untrue written words about another person

Tort

A civil wrong committed against a person or property
Examples include negligence, assault, battery, defamation, fraud, false imprisonment and invasion of privacy