Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX® Examination PDF

Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX® Examination FOURTH EDITION Linda A. LaCharity, PhD, RN Formerly, Accelerated Program Director, Assistant Professor, College of Nursing, University of Cincinnati, Cincinnati, Ohio Candice K. Kumagai, MSN, RN Formerly, Instructor in Clinical Nursing, School of Nursing, University of Texas at Austin, Austin, Texas Barbara Bartz, MN, ARNP Formerly, Nursing Instructor, Yakima Valley Community College, Yakima, Washington With an introduction by Ruth Hansten, PhD, MBA, BSN, RN, FACHE 2 Principal, Hansten Healthcare PLLC, Santa Rosa, California 3 Table of Contents Cover image Title page Copyright Contributors and Reviewers Preface To faculty and other users To students Acknowledgments Part 1: Introduction Introduction Outcomes focus Definition of terms Assignment process Delegation and assignment: the five rights Practice based on research evidence Principles for implementation of prioritization, delegation, and assignment Part 2: Prioritization, Delegation, and Assignment in Common Health Scenarios Chapter 1: Pain Questions 4 Answer Key Chapter 2: Cancer Questions Answer Key Chapter 3: Immunologic Problems Questions Answer Key Chapter 4: Fluid, Electrolyte, and Acid-Base Balance Problems Questions Answer Key Chapter 5: Safety and Infection Control Questions Answer Key Chapter 6: Respiratory Problems Questions Answer Key Chapter 7: Cardiovascular Problems Questions Answer Key Chapter 8: Hematologic Problems Questions Answer Key Chapter 9: Neurologic Problems Questions Answer Key 5 Chapter 10: Visual and Auditory Problems Questions Answer Key Chapter 11: Musculoskeletal Problems Questions Answer Key Chapter 12: Gastrointestinal and Nutritional Problems Questions Answer Key Chapter 13: Diabetes Mellitus Questions Answer Key Chapter 14: Other Endocrine Problems Questions Answer Key Chapter 15: Integumentary Problems Questions Answer Key Chapter 16: Renal and Urinary Problems Questions Answer Key Chapter 17: Reproductive Problems Questions Answer Key Chapter 18: Problems in Pregnancy and Childbearing Questions 6 Answer Key Chapter 19: Pediatric Problems Questions Answer Key Chapter 20: Pharmacology Questions Answer Key Chapter 21: Emergencies and Disasters Questions Answer Key Chapter 22: Psychiatric–Mental Health Problems Questions Answer Key Part 3: Prioritization, Delegation, and Assignment in Complex Health Scenarios Case study 1: Chest Pressure, Indigestion, and Nausea Questions Answer Key Case study 2: Dyspnea and Shortness of Breath Questions Answer Key Case study 3: Multiple Clients on a Medical-Surgical Unit Questions Answer Key Case study 4: Shortness of Breath, Edema, and Decreased Urine Output 7 Questions Answer Key Case study 5: Diabetic Ketoacidosis Questions Answer Key Case study 6: Home Health Questions Answer Key Case study 7: Spinal Cord Injury Questions Answer Key Case study 8: Multiple Patients With Adrenal Gland Disorders Questions Answer Key Case study 9: Multiple Clients With Gastrointestinal Problems Questions Answer Key Case study 10: Multiple Patients With Pain Questions Answer Key Case study 11: Multiple Clients With Cancer Questions Answer Key Case study 12: Gastrointestinal Bleeding Questions Answer Key 8 Case study 13: Head and Leg Trauma and Shock Questions Answer Key Case study 14: Septic Shock Questions Answer Key Case study 15: Heart Failure Questions Answer Key Case study 16: Multiple Patients With Peripheral Vascular Disease Questions Answer Key Case study 17: Respiratory Difficulty After Surgery Questions Answer Key Case study 18: Long-Term Care Questions Answer Key Case study 19: Pediatric Clients in Clinic and Acute Care Settings Questions Answer Key Case study 20: Multiple Patients With Mental Health Disorders Questions Answer Key Case study 21: Childbearing Questions 9 Answer Key Illustration Credits Chapter 1 Chapter 2 Chapter 7 Chapter 10 Chapter 11 Chapter 12 Chapter 13 Chapter 14 Chapter 15 Chapter 19 Chapter 21 Case Study 5 Case Study 13 Case Study 14 10 Copyright 3251 Riverport Lane St. Louis, Missouri 63043 PRIORITIZATION, DELEGATION, AND ASSIGNMENT: PRACTICE EXERCISES FOR THE NCLEX® EXAMINATION, FOURTH EDITION ISBN: 978-0-323-49828-9 Copyright © 2019, Elsevier Inc. All rights reserved. Previous editions copyrighted 2014, 2011, and 2006. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data 11 Names: LaCharity, Linda A., author. | Kumagai, Candice K., author. | Bartz, Barbara, author. Title: Prioritization, delegation, and assignment : practice exercises for the NCLEX examination / Linda A. LaCharity, Candice K. Kumagai, Barbara Bartz ; with an introduction by Ruth Hansten. Description: 4th edition. | St. Louis, Missouri : Elsevier Inc., | Includes bibliographical references. Identifiers: LCCN 2017052329 (print) | LCCN 2017053241 (ebook) | ISBN 9780323498272 (Ebook) | ISBN 9780323498289 (pbk. : alk. paper) Subjects: | MESH: Nursing Care--organization & administration | Delegation, Professional | Nurse's Role | Decision Making | Examination Questions | Case Reports Classification: LCC RT55 (ebook) | LCC RT55 (print) | NLM WY 18.2 | DDC 610.73076--dc23 LC record available at https://lccn.loc.gov/2017052329 Executive Content Strategist: Lee Henderson Content Development Manager: Lisa Newton Associate Content Development Specialist: Laurel Shea Publishing Services Manager: Deepthi Unni Project Manager: Manchu Mohan Design Direction: Margaret Reid Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 12 Contributors and Reviewers CONTRIBUTORS Martha Barry, MS, APN, RN, CNM Certified Nurse Midwife OB Faculty Practice Advocate Medical Group Chicago, Illinois Adjunct Clinical Instructor College of Nursing University of Illinois at Chicago Chicago, Illinois Mary Tedesco-Schneck, PhD Assistant Professor School of Nursing University of Maine Orono, Maine NURSING FACULTY REVIEWERS Sophia Beydoun, MSN, RN Nursing Instructor Health Sciences Division Henry Ford College Dearborn, Michigan Diane Lynn Cooper-McLean, MSN, BSN, RN Department of Allied Health Nursing Faulkner State Community College Bay Minette, Alabama Laura M. Dechant, MSN, APRN, CCRN, CCNS-BC Clinical Nurse Specialist Department of Heart, Vascular, and Interventional Services Christiana Care Health System Newark, Delaware Kathleen Sanders Jordan, DNP, MS, FNP-BC, ENP-BC, SANE-P Clinical Assistant Professor School of Nursing The University of North Carolina at Charlotte Nurse Practitioner Emergency Department Mid-Atlantic Medicine Associates Charlotte, North Carolina Kari Ksar, MS, RN, CPNP Pediatric Nurse Practitioner Division of Pediatric Gastroenterology, Hepatology, and Nutrition Lucile Packard Children’s Hospital at Stanford Palo Alto, California Judi Kuric, DNP, ACNP-BC, ACNPC, CNRN, SCRN Assistant Professor Department of Nursing University of Southern Indiana Acute Care Nurse Practitioner Kentuckiana Neurosurgery Evansville, Indiana Martha E. Langhorne, MSN, RN, FNP, AOCN Nurse Practitioner Department of Gastroenterology Binghamton Gastroenterology, United Health Services Hospitals Binghamton, New York Casey L. Norris, MSN, RN, PCNS-BC Clinical Assistant Professor 13 Department of Nursing The University of Alabama in Huntsville Huntsville, Alabama Charles D. Chad Rogers, MSN, RN Associate Professor of Nursing Department of Nursing Morehead State University Morehead, Kentucky Jenny Lynn Sauls, PhD, MSN, RN, CNE Professor and Director Department of Nursing Middle Tennessee State University Murfreesboro, Tennessee Jane Tyerman, PhD, MScN, BScN, BA, RN Lecturer Fleming School of Nursing Trent University Peterborough Ontario, Canada STUDENT REVIEWERS Sara Allen Lincoln Land Community College Springfield, Illinois Registered Nurse Memorial Medical Center Springfield, Illinois Rebecca Patrick Lincoln Land Community College Springfield, Illinois ER Procedural Technician HSHS St. John’s Hospital Springfield, Illinois 14 Preface Linda A. LaCharity; Candice K. Kumagai; Barbara Bartz Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX® Examination has evolved since its first edition from a medical-surgical nursing– focused test preparation workbook to a resource that spans general nursing knowledge while emphasizing management of care to assist students in preparing for the NCLEX® Examination. A second and equally important purpose of the book is to assist students, novice nurses, and seasoned nurses in applying concepts of prioritization, delegation, and assignment to nursing practice in today’s patient care settings. 15 To faculty and other users Patient care acuity continues to be higher than ever, while staffing shortages remain very real. Nurses must use all available patient care personnel and resources competently and efficiently and be familiar with variations in state laws governing the practice of nursing, as well as differences in scopes of practice and facility-specific job descriptions. Nurses must also be aware of the different skill and experience levels of the health care providers with whom they work on a daily basis. Which nursing actions can be assigned to an experienced versus a new graduate RN or LPN/LVN? What forms of patient care can the nurse delegate to unlicensed assistive personnel (UAP)? Who should help the postoperative patient who has had a total hip replacement get out of bed and ambulate to the bathroom? Can the nurse ask UAPs such as nursing assistants to check a patient’s oxygen saturation using pulse oximetry or check a diabetic patient’s glucose level? What reporting parameters should the nurse give to an LPN/LVN who is monitoring a patient after cardiac catheterization or to the UAP checking patients’ vital signs? What patient care interventions and actions should not be delegated by the nurse? The answers to these and many other questions should be much clearer after completion of the exercises in this book. Exercises in this book range from simple to complex and use various patient care scenarios. The purpose of the chapters and case studies is to encourage the student or new graduate nurse to conceptualize using the skills of prioritization, delegation, and assignment in many different settings. Our goal is to make these concepts tangible to our readers. The questions are written in NCLEX® Examination format to help faculty as they teach student nurses how to prepare for licensure examination. The chapters and case studies focus on real and hypothetical patient care situations to challenge nurses and nursing students to develop the skills necessary to apply these concepts in practice. The exercises are also useful to nurse educators as they discuss, teach, and test their students and nurses for understanding and application of these concepts in nursing programs, examination preparations, and facility orientations. Correct answers, along with in-depth rationales, are provided at the end of each chapter and case study to facilitate the learning process. The faculty exercise keys include QSEN (Quality and Safety Education for Nurses) categories, concepts, and cognitive levels for each question, as well as IPEC (Interprofessional Education Collaborative) categories where appropriate. Additionally, 10 unfolding case studies in PowerPoint format are available on Evolve for use by faculty in the classroom setting. 16 To students Prioritization, delegation, and assignment are essential concepts and skills for nursing practice. Our students and graduate nurses have repeatedly told us of their difficulties with the application of these principles when taking program exit and licensure examinations. Nurse managers have told us many times that novice nurses and even some experienced nurses lack the expertise to effectively and safely practice these skills in real-world settings. Although several excellent resources deal with these issues, there is still a need for a book that incorporates management of care concepts into real-world practice scenarios. Our goal in writing the fourth edition of Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX® Examination is to provide a resource that challenges nursing students, as well as novice and experienced nurses, to develop the knowledge and understanding necessary to effectively apply these important nursing skills: examination preparation and real-world practice. From the original focus on medical-surgical nursing, subsequent editions have expanded to include pediatrics, labor and delivery, psychiatric nursing, and long-term care as well as the role of the nurse in a variety of nonacute care settings. Additionally, we have made changes that reflect the current focus on evidence-based best practices, fundamentals of safe practice, and expansion of diabetes care. For the fourth edition, we responded to requests for more questions, especially about medications. New questions, including drug-related questions, have been added to each chapter, as well as a new pharmacology-focused chapter. We also added questions specific to the needs of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community. New questions were added and revised throughout the book to broaden comprehension of key concepts and knowledge areas and to update current knowledge levels. Each new copy of the book comes with a fully interactive version of the book content, with scoring, on Evolve at http://evolve.elsevier.com/LaCharity/prioritization. This interactive version of the book helps to simulate the experience of taking the NCLEX® Examination. Students can use this interactive option to create multiple different test versions for practice and self-assessment. 17 Acknowledgments We would like to thank the many people whose support and assistance made the creation of the fourth edition of this book possible. Thanks to our families, colleagues, and friends for listening, reading, encouraging, and making sure we had the time to research, write, and review this book. We truly appreciate the expertise of our two contributing authors, Martha Barry (reproductive health) and Mary Tedesco-Schneck (pediatrics), who each contributed an excellent chapter and case study related to their areas of expertise. Special thanks to Ruth Hansten, whose expertise in the area of clinical prioritization, delegation, and assignment skills continues to keep us on track. Many thanks to the faculty and student reviewers, whose expertise helped us keep the scenarios accurate and realistic. Finally, we wish to acknowledge our faculty, students, graduates, and readers who have taken the time to keep in touch and let us know about their needs for additional assistance in developing the skills to practice the arts of prioritization, delegation, and assignment. 18 PA R T 1 Introduction 19 Introduction Ruth Hansten, PhD, MBA, BSN, RN, FACHE 20 Outcomes focus Expert nurses have discovered that the most successful method of approaching their practice is to maintain a laser-like focus on the outcomes that the patients and their families want to achieve. To attempt to prioritize, delegate, or assign care without understanding the patient's preferred results is like trying to put together a jigsaw puzzle without the top of the puzzle box that shows the puzzle picture. Not only does the puzzle player pick up random pieces that don’t fit well together, wasting time and increasing frustration, but also the process of puzzle assembly is fraught with inefficiencies and wrong choices. In the same way, a nurse who scurries haphazardly without a plan, unsure of what could be the most important, lifesaving task to be done first, or which person should do which tasks for this group of patients, is not fulfilling his or her potential to be a channel for healing. Let's visit a change-of-shift report in which a group of nurses receives information about two patients whose blood pressure is plummeting at the same rate. How would one determine which nurse would be best to assign to care for these patients, which patient needs to be seen first, and which tasks could be delegated to assistive personnel, if none of the nurses is aware of each patient's preferred outcomes? Patient A is a young mother who has been receiving chemotherapy for breast cancer; she has been admitted this shift because of dehydration from uncontrolled emesis. She is expecting to regain her normally robust good health and watch her children graduate from college. Everyone on the health care team would concur with her long-term goals. Patient Z is an elderly gentleman, 92 years of age, whose wife recently died from complications of repeated cerebrovascular events and dementia. Yesterday while in the emergency department (ED), he was given the diagnosis of acute myocardial infarction and preexisting severe heart failure. He would like to die and join his wife, has requested a “do not resuscitate” (DNR) order, and is awaiting transfer to a hospice. These two patients share critical clinical data but require widely different prioritization, delegation, and assignment. A savvy charge RN would make the obvious decisions: to assign the most skilled RN to the young mother and to ask assistive personnel to function in a supportive role to the primary care RN. The elderly gentleman needs palliative care and would be best cared for by an RN and care team with excellent people skills. Even a novice nursing assistant could be delegated tasks to help keep Mr. Z and his family comfortable and emotionally supported. The big picture on the puzzle box for these two patients ranges from long-term “robust good health” requiring immediate emergency assessment and treatment to “a supported and comfortable death” requiring timely palliative care, including supportive emotional and physical care. Without envisioning these patients’ pictures and knowing their preferred outcomes, the RNs cannot prioritize, delegate, or assign appropriately. There are many times in nursing practice, however, when correct choices are 21 not so apparent. Patients in all care settings today are often complex, and many have preexisting comorbidities that stump expert practitioners and clinical specialists planning their care. Care delivery systems must flex on a moment's notice as a unlicensed assistive personnel (UAP) arrives in place of a scheduled LPN/LVN (licensed practical nurse/licensed vocational nurse) and agency, float, or traveling nurses fill vacancies, while new patients, waiting to be admitted, accumulate in the ED or wait to be transferred to another setting. Assistive personnel arrive with varying educational preparation and dissimilar levels of motivation and skill. Critical thinking and complex clinical judgment are required from the minute the shift begins until the nurse clocks out. In this book, the authors have filled an educational need for students and practicing nurses who wish to hone their skills in prioritizing, assigning, and delegating. The scenarios and patient problems presented in this workbook are practical, challenging, and complex learning tools. Quality and Safety Education for Nurses (QSEN) competencies are incorporated into this chapter and throughout the questions to highlight patient- and family-centered care, quality and safety improvement, and teamwork and collaboration concepts and skills (QSEN Institute, 2014). Patient stories will stimulate thought and discussion and help polish the higher-order intellectual skills necessary to practice as a successful, safe, and effective nurse. The Core Competencies for Interprofessional Collaborative Practice from Interprofessional Education Collaborative (IPEC) are applied to the questions in this book as appropriate (Interprofessional Education Collaborative, 2016, https://ipecollaborative.org). Domains include (1) Values/Ethics, (2) Roles/Responsibilities, (3) Interprofessional Communication, and (4) Teams/Teamwork (IPEC, 2016). 22 Definition of terms The intellectual functions of prioritization, delegation, and assignment engage the nurse in projecting into the future from the present state. Thinking about what impact might occur if competing decisions are chosen, weighing options, and making split-second decisions, given the available data, is not an easy process. Unless resources in terms of staffing, budget, time, or supplies are unlimited, nurses must relentlessly focus on choosing which issues or concerns must take precedence. Prioritization Prioritizing is defined as “deciding which needs or problems require immediate action and which ones could tolerate a delay in action until a later time because they are not urgent” (Silvestri, 2017). Prioritization in a clinical setting is a process that includes envisioning clearly patient outcomes but also includes predicting possible problems if another task is performed first. One also must weigh potential future events if the task is not completed, the time it would take to accomplish it, and the relationship of the tasks and outcomes. New nurses often struggle with prioritization because they have not yet worked with typical patient progressions through care pathways and have not experienced the complications that may emerge in association with a particular clinical condition. In short, knowing the patient's purpose for care, current clinical picture, and picture of the outcome or result is necessary to be able to plan priorities. The part played by each team member is designated as the RN assigns or delegates. The “four Ps”—purpose, picture, plan, and part—become a guidepost for appropriately navigating these processes (Hansten, 2008a, 2011, 2014b; Hansten and Jackson, 2009). The four Ps will be referred to throughout this introduction because these concepts are the framework on which RNs base decisions about supporting patients and families toward their preferred outcomes, whether RNs provide the care themselves or work closely with assistive team members. Prioritization includes evaluating and weighing each competing task or process using the following criteria (Hansten and Jackson, 2009, pp. 194–196): Is it life threatening or potentially life threatening if the task is not done? Would another patient be endangered if this task is done now or the task is left for later? Is this task or process essential to patient or staff safety? Is this task or process essential to the medical or nursing plan of care? In each case, an understanding of the overall patient goals and the context and setting is essential. In her book on critical thinking and clinical judgment, Rosalinda Alfaro- Lefevre (2017) suggests three levels of priority setting: 1. The first level is airway, breathing, cardiac status and circulation, and vital signs and lab values that could be life threatening (“ABCs plus V and L”). 23 2. The second level is immediately subsequent to the first level and includes concerns such as mental status changes, untreated medical issues, acute pain, acute elimination problems, and imminent risks. 3. The third level is health problems other than those at the first two levels, such as more long-term issues in health education, rest, coping, and so on (p. 171). Maslow's hierarchy of needs can be used to prioritize from the most crucial survival needs to needs related to safety and security, affiliation (love, relationships), self-esteem, and self-actualization (Alfaro-Lefevre, 2017, p. 170). Delegation and Assignment The official definitions of assignment have been altered through ongoing discussion among nursing leaders, and terminology distinctions such as observation versus assessment, critical thinking versus clinical reasoning, and delegation versus assignment continue to be contentious as nursing leaders attempt to describe complex thinking processes that occur in various levels of nursing practice. Historically, the definition of assignment was “designating nursing activities to be performed by another nurse or assistive personnel that are consistent with his/her scope of practice (licensed person) or role description (unlicensed person)” (National Council of State Boards of Nursing [NCSBN], 2004). In 2016, the NCSBN published the results of two expert panels to clarify that assignment includes “the routine care, activities, and procedures that are within the authorized scope of practice of the RN or LPN/LVN or part of the routine functions of the UAP (Unlicensed Assistive Personnel)... that are included in the coursework taught in the delegatee's basic educational program” (NCSBN, 2016b, p. 6-7). Delegation was defined as “transferring to a competent individual the authority to perform a selected nursing task in a selected situation” (NCSBN, 1995). This definition of delegation remains the current definition for purposes of this book. Both the American Nurses Association (ANA) and the NCSBN describe delegation as “the process for a nurse to direct another person to perform nursing tasks and activities.” The ANA specifies that delegation is a transfer of responsibility rather than authority (ANA and NCSBN, 2006, p. 1). Some state boards have argued that “assignment” is the process of directing a nursing assistant to perform a task such as taking blood pressure, a task on which nursing assistants are tested in the certified nursing assistant examination and that would commonly appear in a job description. Others contend that all nursing care is a part of the RN scope of practice and therefore that such a task would be “delegated” rather than “assigned.” Other nursing leaders argue that only when a task is clearly within the RN's scope of practice, and not included in the role of the assistive personnel, is the task delegated. In 2006, the ANA and the NCSBN collaborated in their Joint Statement on Delegation and altered the definition of assignment to “describes the distribution of work that each staff member is responsible for during a given shift or work period” (ANA and NCSBN, 2006, p. 1). This “work plan” 24 terminology is the definition of assignment used in this workbook, and it connotes the nursing leadership role of human resources deployment in a manner that most wisely promotes the patient's and family's preferred outcome. Although states vary in their definitions of the functions and processes in professional nursing practice, including that of delegation, the authors use the NCSBN definition, including the caveat present in the sentence following the definition: delegation is “transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains the accountability for the delegation” (NCSBN, 1995, p. 2). Assignments are work plans that would include tasks the delegatee would have been trained to do in their basic educational program; the nurse “assigns” or distributes work and also “delegates” nursing care as she or he works through others. In advanced UAP roles such as when certified medication aides are taught to administer medications or when certified medical assistants give injections, the NCSBN (2016) asserts that because of the extensive responsibilities involved, the employers and nurse leaders in the settings where certified medication aides are employed, such as ambulatory care, skilled nursing homes, or home health settings, should regard these procedures as being delegated and UAP competencies must be assured (NCSBN, 2016b, p. 7). However, this differentiation between delegation and assignment is perplexing to nurses. Because both processes are identical in terms of the actions and thinking processes of the RN from a practical standpoint, the distinctions are confusing and irrelevant for the purposes of this text. In its seminal 2005 delegation White Paper, the NCSBN states that “using the verb assign in this manner [as in the above 2004 definition] is a variation of delegation. Since the process for both is the same, this Paper uses the verb ‘delegate’ to describe the process of working through others and the noun ‘assignment’ to describe what a person is directed to do (reflecting the common usage of language among nurses working in clinical settings)” (NCSBN, 2005, p. 174). In all cases, whether assigning or delegating, the RN is accountable for the total nursing care of the patient and for making choices about which competent person is permitted to perform each task successfully. Delegation and Supervision The definition of delegation alone offers some important clues to nursing practice and to the composition of an effective patient care team. The person who makes the decision to ask a person to do something (a task or assignment) must know that the chosen person is competent to perform that task. The RN selects the particular task, given his or her knowledge of the individual patient's condition and that particular circumstance. Because of the nurse's preparation, knowledge, and skill, the RN chooses to render judgments of this kind and stands by the choices made. According to licensure and statute, the nurse is obligated to delegate based on the unique situation, patients, and personnel involved and to provide ongoing follow-up. 25 Supervision Whenever a nurse delegates, he or she must also supervise. Supervision is defined by the NCSBN as “the provision of guidance and direction, oversight, evaluation and follow up by the licensed nurse for accomplishment of a nursing task delegated to nursing assistive personnel” (NCSBN, 2005, p. 194). The act of delegating is just the beginning of the RN's responsibility. As for the accountability of the delegatees (or persons given the task duty), these individuals are accountable for “[accepting] the delegation and for their own actions in carrying out the act” (NCSBN, 1995, p. 3). For example, nursing assistants who are unprepared or untrained to complete a task should say as much when asked and can then decline to perform that particular duty. In such a situation, the RN would determine whether to allocate time to train the assistive personnel and review the skill as it is learned, to delegate the task to another competent person, to do it herself or himself, or to make arrangements for later skill training. The ANA defines supervision as “the provision of guidance or direction, guiding, and influencing the outcome of an individual's performance of a task” (ANA and NCSBN, 2006, p. 1). In both definitions, it is clear that the RN's job continues throughout the performance and results of task completion. Scope of Practice for RNs, LPNs/LVNs, and UAPs Heretofore this text has discussed national recommendations for definitions. National trends suggest that nursing is moving toward standardized licensure through mutual recognition compacts and multistate licensure, and as of July 2016, 25 states had adopted the nurse license compact allowing a nurse in a member state to possess one state's license and practice in another member state, with six states pending (NCSBN, 2016c). Standardized and multistate licensure supports electronic practice and promotes improved practice flexibility. However, each RN must know his or her own state's regulations. Except for the 25 licensure compact participants, definitions still differ from state to state, as do regulations about the tasks that nursing assistants or other assistive personnel are allowed to perform in various settings. For example, UAPs are delegated tasks for which they have been trained and that they are currently competent to perform for stable patients in uncomplicated circumstances; these are routine, simple, repetitive, common activities not requiring nursing judgment, for example, activities of daily living, hygiene, feeding, and ambulation. Some states have generated statutes and/or rules that list specific tasks that can or cannot be delegated (NCSBN, 2005, pp. 178–179). However, trends indicate that more tasks will be delegated as research supports such delegation through evidence of positive outcomes. Acute care hospitals nursing assistants have not historically been authorized to administer medications. In some states, specially certified medication assistants administer oral medications in the community (group homes) and in some long-term care facilities, although there is substantial variability in state- 26 designated CNA duties (McMullen et al., 2015). More states are employing specially trained nursing assistants as CMAs (Certified Medication Assistants) or MA-Cs (Medication Assistants-Certified) to administer routine, nonparenteral medications in long-term care or community settings with training as recommended by the NCSBN's Model Curriculum (NCSBN, 2007). In Washington State in 2008, a process was initiated to alter the statute and related administrative codes to allow trained nursing assistants in home or community-based settings, such as boarding homes and adult family homes, to administer insulin if the patient is an appropriate candidate (in a stable and predictable condition) and if the nursing assistant has been appropriately trained and supervised for the first 4 weeks of performing this task (Revised Code of Washington, 2012). Consistency of state regulation of UAP medication administration in residential care and adult day-care settings has been stated to be inadequate to ensure RN oversight of assistive personnel (Carder and O’Keeffe, 2016). This research finding should serve as a caution for all practicing in these settings. In all states, nursing judgment is used to delegate tasks that fall within, but never exceed, the nurse's legal scope of practice, and an RN always makes decisions based on the individual patient situation. An RN may decide not to delegate the task of feeding a patient if the patient is dysphagic and the nursing assistant is not familiar with feeding techniques. A “Lessons Learned from Litigation” article in the American Journal of Nursing in May 2014 describes the hazards of improper RN assignment, delegation, and supervision of patient feeding, resulting in a patient's death and licensure sanctions (Brous, 2014). The scope of practice for LPNs or LVNs also differs from state to state and is continually evolving. For example, in Texas and Colorado, LPNs have been prohibited from delegating nursing tasks; only RNs are allowed to delegate (Hansten and Jackson, 2009, p. 91). In 23 states in 2004 and in 28 states in 2005, LPNs were allowed to delegate, and in 33 states, they were allowed to assign (NCSBN, 2005, pp. 112, 178–179). Although practicing nurses know that LPNs often review a patient's condition and perform data-gathering tasks such as observation and auscultation, RNs remain accountable for the total assessment of a patient, including synthesis and analysis of reported and reviewed information to lead care planning based on the nursing diagnosis. A large majority of 48 state board respondents (46 to 2) indicated that LPNs/LVNs were not allowed to develop plans of care independently, but many (14) commented that the LPN could contribute to the care plan (NCSBN, 2005, pp. 108–109). In their periodic review of actual practice by recent PN (practical nurse) test participants employed in hospitals, long-term care, and home health, in 2006 the NCSBN discovered that more than three fourths of recent graduates contributed to development of the plan of care, almost 90% took verbal or telephone orders from physicians, approximately half administered or monitored IV piggyback medications, about 40% inserted nasogastric tubes, and about 30% had monitored blood transfusions (NCSBN, 2008, pp. 30–38). In an updated 2009 NCSBN survey of 1400 practicing LPNs, 85.4% assigned client care or related tasks to other LPNs or assistive personnel, and 81.2% supervised 27 or evaluated activities of assistive personnel, with 65.8% working in long-term care settings (NCSBN, 2010, p. 35). IV therapy and administration of blood products or total parenteral nutrition (TPN) by LPNs/LVNs also vary widely. A 2015 survey showed that although labor and delivery knowledge was deemed by LPN/LVNs, supervisors, and educators as one of the least important concepts to learn (possibly because of infrequent use of LPN/LVNs in labor areas), blood product transfusion topics were considered vital for basic LPN/LPN education (NCSBN, 2016a, pp. 24–26). Even in states where regulations allow LPNs/LVNs to administer blood products, a given health care organization's policies or job descriptions may limit practice and place additional safeguards because of the life-threatening risk involved in the administration of blood products and other medications. The RN must review the agency's job descriptions as well as the state regulations because either are changeable. LPN/LVN practice continues to evolve, and in any state, tasks to support the assessment, planning, intervention, and evaluation phases of the nursing process can be allocated. When it is clear that a task could possibly be delegated to a skilled delegatee according to your state's scope of practice rules and is not prohibited by the organization policies, the principles of delegation and/or assignment remain the same. The totality of the nursing process remains the responsibility of the RN. Also, the total nursing care of the patient rests squarely on the RN's shoulders, no matter which competent and skilled individual is asked to perform care activities. To obtain more information about the statute and rules in a given state and to access decision trees and other helpful aides to delegation and supervision, visit the NCSBN website at http://www.ncsbn.org. The state practice act for each state is linked at that site. 28 Assignment process In current hospital environments, the process of assigning or creating a work plan is dependent on who is available, present, and accounted for and what their roles and competencies are for each shift. Assignment “describes the distribution of work that each staff member is responsible for during a given shift or work period” (ANA and NCSBN, 2006, p. 1). Classical care delivery models once known as total patient care have been transformed into a combination of team, functional, and primary care nursing, depending on the projected patient outcomes, the present state, and the available staff. Assignments must be created with knowledge of the following issues (Hansten and Jackson, 2009, pp. 207–208): How complex is the patients’ required care? What are the dynamics of patients’ status and their stability? How complex is the assessment and ongoing evaluation? What kind of infection control is necessary? Are there any individual safety precautions? Is there special technology involved in the care, and who is skilled in its use? How much supervision and oversight will be needed based on the staff's numbers and expertise? How available are the supervising RNs? How will the physical location of patients affect the time and availability of care? Can continuity of care be maintained? Are there any personal reasons to allocate duties for a particular patient, or are there nurse or patient preferences that should be taken into account? Factors such as staff difficulties with a particular diagnosis, patient preferences for an employee's care on a previous admission, or a staff member's need for a particular learning experience will be taken into account. Is there an acuity rating system that will help distribute care based on a point or number system? For more information on care delivery modalities, refer to the texts by Hansten and Jackson (2009) and Alfaro-LeFevre (2017) listed in the References section. Whichever type of care delivery plan is chosen for each particular shift or within your practice arena, the relationship with the patient and the results that the patient wants to achieve must be foremost, followed by the placing together of the right pieces in the form of competent team members, to compose the complete picture (Hansten, 2005a, 2008a). 29 Delegation and assignment: the five rights As you contemplate the questions in this workbook, you can use mnemonic devices to order your thinking process, such as the “five rights.” The right task is assigned to the right person in the right circumstances. The RN then offers the right direction and communication and the right supervision and evaluation (Hansten and Jackson, 2009, pp. 205–206; NCSBN, 1995, pp. 2–3, Hansten, 2014a, p. 70; NCSBN, 2016b, p 8). Right Circumstances Recall the importance of the context in clinical decision making. Not only do rules and regulations adjust based on the area of practice (i.e., home health care, acute care, long-term care), but patient conditions and the preferred patient results must also be considered. If information is not available, a best judgment must be made. Often RNs must balance the need to know as much as possible and the time available to obtain the information. The instability of patients immediately postoperatively or in the intensive care unit (ICU) means that a student nurse will have to be closely supervised and partnered with an experienced RN. The questions in this workbook give direction as to context and offer hints to the circumstances. For example, in long-term care skilled nursing facilities, LPNs/LVNs often function as “team leaders” with ongoing care planning and oversight by a smaller number of on-site RNs. Some EDs use paramedics, who may be regulated by the state emergency system statutes, in different roles in hospitals. Medical clinics often employ “medical assistants” who function under the direction and supervision of physicians, other providers, and RNs. Community group homes, assisted living facilities, and other health care providers beyond acute care hospitals seek to create safe and effective care delivery systems for the growing number of older adults. Whatever the setting or circumstance, the nurse is accountable to know the specific laws and regulations that apply. Right Task Returning to the guideposts for navigating care, the patient's four Ps (purpose, picture, plan, and part), the right task is a task that, in the nurse's best judgment, is one that can be safely delegated for this patient, given the patient's current condition (picture) and future preferred outcomes (purpose, picture), if the nurse has a competent individual to perform it. Although the RN may believe that he or she personally would be the best person to accomplish this task, the nurse must prioritize the best use of his or her time given a myriad of factors. “What other tasks and processes must I do because I am the only RN on this team? Which tasks can be delegated based on state regulations and my thorough knowledge of job descriptions here in this facility? How skilled are the personnel working here today? Who else could be available to help if 30 necessary?” In its draft model language for nursing assistive personnel, the NCSBN lists criteria for determining nursing activities that can be delegated. The following are recommended for the nurse's consideration. It should be kept in mind that the nursing process and nursing judgment cannot be delegated. Knowledge and skills of the delegatee Verification of clinical competence by the employer Stability of the patient's condition Service setting variables such as available resources (including the nurse's accessibility) and methods of communication, complexity and frequency of care, and proximity and numbers of patients relative to staff Assistive personnel are not to be allocated the duties of “ongoing assessment, interpretation, or decision making that cannot be logically separated from the procedures” (NCSBN, 2005, p. 197). Right Person Licensure, Certification, and Role Description One of the most commonly voiced concerns during workshops with staff nurses across the nation is, “How can I trust the delegatees?” Knowing the licensure, role, and preparation of each member of the team is the first step in determining competency. What tasks does a PCT (patient care technician) perform in this facility? What is the role of an LPN/LVN? Are different levels of LPN/LVN designated here (LPN I or II)? Nearly 100 different titles for assistive personnel have been developed in care settings across the country. To effectively assign or delegate, the RN must know the role descriptions of co-workers as well as his or her own. Strengths and Weaknesses The personal strengths and weaknesses of usual team members are no mystery. Their skills are discovered through practice, positive and negative experiences, and an ever-present but unreliable rumor mill. An expert RN helps create better team results by using strengths in assigning personnel to exploit their gifts. The most compassionate team will work with the hospice patient and his or her family. The supervising nurse helps identify performance flaws and develops staff by providing judicious use of learning assignments. For example, a novice nursing assistant can be partnered with an experienced oncology RN during the assistant's first experiences with a terminally ill patient. When working with students, float nurses, or other temporary personnel, nurses sometimes forget that the assigning RN has the duty to determine competency. Asking personnel about their previous experiences and about their understanding of the work duties, as well as pairing them with a strong unit staff member, is as essential as providing the ongoing support and supervision needed throughout the shift. If your mother were an ICU patient and her nurse were an inexperienced float from the rehabilitation unit, what level of 31 leadership and direction would that nurse need from an experienced ICU RN? Many hospitals delegate only tasks, a functional form of assignment, to temporary personnel who are unfamiliar with the clinical area. Right Direction and Communication Now that the right staff member is being delegated the right task for each particular situation and setting, team members must find out what they need to do and how the tasks must be done. Relaying instructions about the plan for the shift or even for a specific task is not as simple as it seems. Some RNs believe that a written assignment board provides enough information to proceed because “everyone knows his or her job,” but others spend copious amounts of time giving overly detailed directions to bored staff. The “four Cs” of initial direction will help clarify the salient points of this process (Hansten and Jackson, 2009, pp. 287–288; 2012, pp. 299–300). Instructions and ongoing direction must be clear, concise, correct, and complete. Clear communication is information that is understood by the listener. An ambiguous question such as: “Can you get the new patient?” is not helpful when there are several new patients and returning surgical patients, and “getting” could mean transporting, admitting, or taking full responsibility for the care of the patient. Asking the delegatee to restate the instructions and work plan can be helpful to determine whether the communication is clear. Concise statements are those that give enough but not too much additional information. The student nurse who merely wants to know how to turn on the chemical strip analyzer machine does not need a full treatise on the transit of potassium and glucose through the cell membrane. Too much or irrelevant information confuses the listener and wastes precious time. Correct communication is that which is accurate and is aligned to rules, regulations, or job descriptions. Are the room number, patient name, and other identifiers correct? Are there two patients with similar last names? Can this task be delegated to this individual? Correct communication is not cloudy or confusing (Hansten and Jackson, 2009, pp. 287–288; 2012, p. 299). Complete communication leaves no room for doubt on the part of supervisor or delegatees. Staff members often say, “I would do whatever the RNs want if they would just tell me what they want me to do and how to do it.” Incomplete communication wins the top prize for creating team strife and substandard work. Assuming that staff “know” what to do and how to do it, along with what information to report and when, creates havoc, rework, and frustration for patients and staff alike. Each staff member should have in mind a clear map or plan for the day, what to do and why, and what and when to report to the team leader. Parameters for reporting and the results that should be expected are often left in the team leader's brain rather than being discussed and spelled out in sufficient detail. RNs are accountable for clear, concise, correct, and complete initial and ongoing direction. 32 Right Supervision and Evaluation After prioritization, assignment, and delegation have been considered, determined, and communicated, the RN remains accountable for the total care of the patients throughout the tour of duty. Recall that the definition of supervision includes not only initial direction but also that “supervision is the active process of directing, guiding, and influencing the outcome of an individual's performance of a task. Similarly, NCSBN defines supervision as the provision of guidance or direction, oversight, evaluation and follow-up by the licensed nurse for the accomplishment of a delegated nursing task by assistive personnel” (ANA and NCSBN, 2006, p. 1). RNs may not actually perform each task of care, but they must oversee the ongoing progress and results obtained, reviewing staff performance. Evaluation of the care provided, and adequate documentation of the tasks and outcomes, must be included in this last of the five rights. On a typical unit in an acute care facility, assisted living, or long- term care setting, the RN can ensure optimal performance as the RN begins the shift by holding a short “second report” meeting with assistive personnel, outlining the day's plan and the plan for each patient, and giving initial direction at that time. Subsequent short team update or “checkpoint” meetings should be held before and after breaks and meals and before the end of the shift (Hansten, 2005b, 2008a, 2008b). During each short update, feedback is often offered, and plans are altered. The last checkpoint presents all team members with an opportunity to give feedback to one another using the step-by-step feedback process (Hansten, 2008a, pp. 79–84; Hansten and Jackson, 2012, pp. 301–302). This step is often called the “debriefing” checkpoint or huddle, in which the team's processes are also examined. In ambulatory care settings, this checkpoint may be toward the end of each patient's visit or the end of the shift; in home health care, these conversations are often conducted on a weekly basis. Questions such as, “What would you recommend I do differently if we worked together tomorrow on the same group of patients? What can we do better as a team to help us navigate the patients toward their preferred results?” will help the team function more effectively in the future. 1. The team member's input should be solicited first. “I noted that the vital signs for the first four patients aren’t yet on the electronic record. Do you know what's been done?” rather than “WHY haven’t those vital signs been recorded yet?” At the end of the shift, the questions might be global, as in “How did we do today?” “What would you do differently if we had it to do over?” “What should I do differently tomorrow?” 2. Credit should be given for all that has been accomplished. “Oh, so you have the vital signs done, but they aren’t recorded? Great, I’m so glad they are done so I can find out about Ms. Johnson's temperature before I call Dr. Smith.” “You did a fantastic job with cleaning Mr. Orange after his incontinence episodes; his family is very appreciative of our respect for his dignity.” 3. Observations or concerns should be offered. “The vital signs are routinely recorded on the EMR [electronic medical record] before patients are sent 33 for surgery and procedures and before the doctor's round so that we can see the big picture of patients’ progress before they leave the unit and to make sure they are stable for their procedures.” Or, “I think I should have assigned another RN to Ms. Apple. I had no idea that your mother recently died of breast cancer.” 4. The delegatee should be asked for ideas on how to resolve the issue. “What are your thoughts on how you could order your work to get the vital signs on the EMR before 8:30 am?” Or, “What would you like to do with your work plan for tomorrow? Should we change Ms. Apple's team?” 5. A course of action and plan for the future should be agreed upon. “That sounds great. Practice use of the handheld computers today before you leave, and that should resolve the issue. When we work together tomorrow, let me know whether that resolves the time issue for recording; if not, we will go to another plan.” Or, “If you still feel that you want to stay with this assignment tomorrow after you’ve slept on it, we will keep it as is. If not, please let me know first thing tomorrow morning when you awaken so we can change all the assignments before the staff arrive.” 34 Practice based on research evidence Rationale for Maximizing Nursing Leadership Skills at the Point of Care If the skills presented in this book are used to save lives by providing care prioritized to attend to the most unstable patients first, optimally delegated to be delivered by the right personnel, and assigned using appropriate language with the most motivational and conscientious supervisory follow-up, then clinical outcomes should be optimal and work satisfaction should flourish. As stated in a 2008 article in Nurse Leader, solid correlational research evidence is lacking related to “the best use of personnel to multiply the RN's ability to remain vigilant over patient progress and avoid failures to rescue, but common sense would advise that better delegation and supervision skills would prevent errors and omissions as well as unobserved patient decline” (Hansten, 2008b). In an era of value-based purchasing and health care reimbursement based on clinical results with linkages for care along the continuum from site to site, an RN's accountability has irrevocably moved beyond task orientation to leadership practices that ensure better outcomes for patients, families, and populations. The necessity of efficiency and effectiveness in health care means that RNs must delegate and supervise appropriately so that all tasks that can be safely assigned to UAPs are completed flawlessly. Patient safety experts have linked interpersonal communication errors and teamwork communication gaps as major sources of medical errors while The Joint Commission associated these as root causes of 70% or more of serious reportable events (Grant, 2016, p 11). Nurses are accountable for processes as well as outcomes measures so that insurers will reimburse health care organizations. If hospital-acquired conditions occur, such as pressure ulcers, falls with injury, and some infections, reimbursement for the care of that condition will be negatively impacted. Nurses spend from 10% to 25% of their shifts looking for other staff members (Tucker and Spear, 2006). Better initial direction and a plan for supervision during the day decrease time wasted in attempting to connect with team members. At one facility in the Midwest, shift hand-offs were reduced to 10 to 15 minutes per shift per RN as a result of a planned approach to initial direction and care planning, which thus saved each RN 30 to 45 minutes per day (Hansten, 2008a, p. 34). Better use of nursing and UAP time can result in more time to care for patients, giving RNs the opportunity to teach patients self-care or to maintain functional status. When nurses did not appropriately implement the five rights of delegation and supervision with assistive personnel, errors occurred that potentially could have been avoided with better RN leadership behaviors. About 14% of task errors or care omissions related to teamwork were due to lack of RN direction or communication, and approximately 12% of the issues stemmed from lack of supervision or follow-up (Standing, Anthony, and Hertz, 2001). 35 Errors can result in uncompensated conditions or readmissions; unhappy patients and providers; disgruntled health care purchasers; and a disloyal, anxious patient community. Teamwork and job satisfaction have been found to be negatively correlated with over-delegation and a hierarchical relationship between nurses and assistive personnel (Kalisch and Begeny, 2005), but offering feedback effectively has been shown to improve team thinking and performance (Kozlowski and Ilgen, 2007). When staff in a long-term care facility were able to connect their work with personal purposes and patient results, there were a 23% increase in teamwork, a 10% jump in job satisfaction, a 17% increase in morale, and a $12,000 drop in absenteeism costs (Kinjerski and Skrypnek, 2008). Best practices for deployment of personnel include a connection to patient outcomes, which can occur during initial direction and debriefing supervision checkpoints. Unplanned readmissions to acute care within 30 days of discharge are linked to potential penalties and reduced reimbursement. Inadequate RN initial direction and supervision of UAPs can lead to missed mobilization, hydration, and nutrition of patients, thereby discharging deconditioned patients, and can be traced to ED visits and subsequent readmissions. Reimbursement bundling for specific care pathways such as total joint replacements or acute exacerbation of COPD (chronic obstructive pulmonary disease) requires that team communication and RN supervision of coworkers along the full continuum must be seamless from ambulatory care to acute care, rehabilitation, and home settings. As public quality transparency and competition for best value becomes the norm, ineffective delegation has been a significant source of missed care, such as lack of care planning, lack of turning or ambulation, delayed or missed nutrition, and lack of hygiene (Bittner et al., 2011; Kalisch, 2006). These care omissions can be contributing factors for the occurrence of unreimbursed “never events” (events that should never occur) such as pressure ulcers and pneumonia, as well as prolonged lengths of stay. Other nurse-sensitive quality indicators such as catheter-associated urinary tract infections (CAUTIs) could be correlated to omitted perineal hygiene and inattention to discontinuation of catheters. Useful models that link delegation with care omissions and ensuing care hazards such as thrombosis, pressure ulcers, constipation and infection, combined with a Swiss Cheese Safety Model showing defensive steps against health care– acquired conditions and errors through excellence in RN leadership can be accessed in the August 2004 Nurse Leader at https://doi.org/10.1016/j.mnl.2013.10.007 (Hansten, 2014a). Evidence does indicate that appropriate nursing judgment in prioritization, delegation, and supervision can save time and improve communication and thereby improve care, patient safety, clinical outcomes, and job satisfaction, potentially saving patient-days and absenteeism and recruitment costs. Patient satisfaction, staff satisfaction, and clinical results decline when nursing care is poor. Potential reimbursement is lost, patients and families suffer, and the 36 health of our communities decays when RNs do not assume the leadership necessary to work effectively with all team members (Bittner et al., 2011). 37 Principles for implementation of prioritization, delegation, and assignment Return to our goalposts of the four Ps (purpose, picture, plan, and part) as a framework as you answer the questions in this workbook and further develop your own expertise and recall the following principles: The RN should always start with the patient's and family's preferred outcomes in mind. The RN is first clear about the patient's purpose for accessing care and his or her picture for a successful outcome. The RN should refer to the applicable state nursing practice statute and rules as well as the organization's job descriptions for current information about roles and responsibilities of RNs, LPNs/LVNs, and UAPs. (These are the roles or the part that people play.) Student nurses, novices, float nurses, and other infrequent workers also require variable levels of supervision, guidance, or support. (The workers’ abilities and roles become a piece of the plan [Hansten and Jackson, 2009, pp. 52–55].) The RN is accountable for nursing judgment decisions and for ongoing supervision of any care that is delegated or assigned. The RN cannot delegate the nursing process (in particular the assessment, planning, and evaluation phases) or clinical judgment to a non-RN. Some interventions or data-gathering activities may be delegated based on the circumstances. The RN must know as much as practical about the patients and their conditions, as well as the skills and competency of team members, to prioritize, delegate, and assign. Decisions must be specifically individualized to the patient, the delegatees, and the situation. In a clinical situation, everything is fluid and shifting. No priority, assignment, or delegation is written indelibly and cannot be altered. The RN in charge of a unit, a team, or one patient is accountable to choose the best course to achieve the patient's and family's preferred results. Good luck in completing the workbook! The authors invite you to use the questions as an exercise in assembling the pieces to the puzzle that will become a picture of health-promoting practice. 38 References Alfaro-Lefevre R. Critical thinking, clinical reasoning, and clinical judgment: a practical approach. ed 6 St Louis: Saunders; 2017. American Nurses Association, National Council of State Boards of Nursing. Joint statement on delegation. retrieved May 31, 2012, from 2006. http://www.ncsbn.org/joint_statement/pdf. Bittner N., Gravlin G., Hansten R., Kalisch B. Unraveling care omissions. J Nurs Adm. 2011;41(12):510–512. Brous E. Lessons learned from litigation: the case of Bernard Travaglini. Am J Nurs. (114):2014;68–70 5. Carder P.C., O’Keeffe J. State regulation of medication administration by unlicensed assistive personnel in residential care and adult day services settings. Res Gerontol Nurs. 2016;7:1–14. Grant V. Sharpening your legal IQ: safeguarding your license. Viewpoint. 2016;38(3):10–12. Hansten R. Relationships and results: solid patient relationships can improve clinical outcomes. Healthc Exec. 2005a;20(4):34–35. Hansten R. Relationship and results-oriented healthcare: evaluate the basics. J Nurs Adm. 2005b;35(12):522–524. Hansten R. Leadership at the point of care: nursing delegation. 2011. retrieved May 31, 2012, from http://www.MyFreeCE.com. Hansten R. Relationship and results oriented healthcare™ planning and implementation manual. Port Ludlow, Wash: Hansten Healthcare PLLC; 2008a. Hansten R. Why nurses still must learn to delegate. Nurse Leader. 2008b;6(5):19–26. Hansten R., Jackson M. Clinical delegation skills: a handbook for professional practice. ed 4 Sudbury, Mass: Jones & Bartlett; 2009. Hansten R., Jackson M. Delegation in the clinical setting. In: Zerwekh J., Claborn J., eds. Nursing today: transitions and trends. ed 7 St Louis: Elsevier; 2012. Hansten R. Coach as chief correlator of tasks to results through delegation skill and teamwork development. Nurse Leader. 2014a;12(4):69–73. Hansten R. The Master Coach Manual for the Relationship & Results Oriented Healthcare Program. Port Ludlow, Wash: Hansten Healthcare PLLC; 2014b. Interprofessional Education Collaborative. Domain listing in Core Competencies Report. pp. 9–11. IPEC 2016, retrieved August 11, 2016, from https://ipecollaborative.org/uploads/IPEC-2016-Updated-Core- Competencies-Report__final_release_.PDF Kalisch B. Missed nursing care. J Nurs Care Qual. 2006;21(4):306–313. Kalisch B., Begeny S. Improving nursing unit teamwork. J Nurs Adm. 2005;35(12):550–556. Kinjerski V., Skrypnek B. The promise of spirit at work. J Gerontol Nurs. 39 2008;34(10):17–25. Kozlowski S., Ilgen D. The science of team success. Sci Am Mind. 2007;June-July:54–61. McMullen T.L., Resnick B., Chin-Hansen J., et al. Certified nurse aide scope of practice: state-by-state differences in allowable delegated activities. J Am Med Dir Assoc. 2015;6(1):20–24. National Council of State Boards of Nursing: Delegation: concepts and decision-making process, Issues December:1–4, 1995. National Council of State Boards of Nursing: NCSBN Model Nurse Practice Act, 2004, Article III, Section 4C, retrieved August 8, 2005, from http://www.ncsbn.org/regulation/nursing. National Council of State Boards of Nursing: Business book: NCSBN annual meeting: mission possible: building a safer nursing workforce through regulatory excellence, 2005, retrieved August 12, 2005, from http://www.ncsbn.org/pdfs/V_Business_Book_Section_I.pdf. National Council of State Boards of Nursing: Medication assistant model curriculum, 2007, retrieved May 31, 2012, from https://www.ncsbn.org/07_Final_MAC.pdf. National Council of State Boards of Nursing: Report of findings from the 2006 LPN/VN practice analysis comparability of survey administration methods, Research Brief (Vol 33), Chicago, 2008, The Council. National Council of State Boards of Nursing: 2009 LPN/VN practice analysis: linking the NCLEX-PN® examination to practice, March 2010, Research Brief (Vol 44), retrieved May 31, 2012, from https://www.ncsbn.org/10_LPN_VN_PracticeAnalysis_Vol44_web.pdf. National Council of State Boards of Nursing. 2016. Report of Findings from the 2015 LPN/VN Nursing Knowledge Survey. NCSBN Research Brief (66): March 2016a, retrieved July 18, 2016, from https://www.ncsbn.org/16_LPN_KSA_vol66.pdf. National Council of State Boards of Nursing: National guidelines for nursing delegation. J Nurs Reg 7(1):5–14, 2016b. National Council of State Boards of Nursing: Participating states in the nurse licensure compact implementation, 2016c, retrieved July 14, 2016, from https://www.ncsbn.org/2538.htm. QSEN Institute, 2014, Nursing outlook special issue: quality and safety education, retrieved from http://qsen.org/competencies/graduate-ksas/. Revised Code of Washington, Title 18, Chapter 18.79, Section 18.79.260, Registered nurse—activities allowed—delegation of tasks, 2008, retrieved May 31, 2012, from http://apps.leg.wa.gov/RCW/default.aspx? cite=18.79.260. Silvestri L. Saunders comprehensive review for the NCLEX-RN® examination. ed 7 St Louis: Saunders; 2017. Standing T., Anthony M., Hertz J. Nurses’ narratives of outcomes after delegation to unlicensed assistive personnel. Outcomes Manag Nurs Pract. 2001;5(1):18–23. Tucker A., Spear S. Operational failures and interruptions in hospital 40 nursing. Health Serv Res. 2006;41(3 Pt 1):643–662. 41 Recommended resources Alfaro-Lefevre R. Critical thinking, clinical reasoning, and clinical judgment: a practical approach. ed 6 St Louis: Saunders; 2017. Hansten R. The Master Coach Manual for the Relationship & Results Oriented Healthcare Program. Port Ludlow, Wash: Hansten Healthcare PLLC; 2014. Hansten R. Relationship and results oriented healthcare™ planning and implementation manual. Port Ludlow, Wash: Hansten Healthcare PLLC; 2008. Hansten R., Jackson M. Clinical delegation skills: a handbook for professional practice. ed 4 Sudbury, Mass: Jones & Bartlett; 2009. Hansten R. Coach as chief correlator of tasks to results through delegation skill and teamwork development. Nurse Leader 12(4):69–73. Hansten Healthcare PLLC website, http://www.Hansten.com or http://www.RROHC.com. Check for new delegation/supervision resources, online delegation, and assignment education modules at http://learning.Hansten.com. National Council of State Boards of Nursing website, http://www.ncsbn.org. Contains links to state boards and abundant resources relating to delegation and supervision. Also download the ANA and NCSBN Joint Statement on Delegation. The decision trees and step-by-step process through the five rights are exceptionally clear and a great review to prepare for the NCLEX. 42 PA R T 2 Prioritization, Delegation, and Assignment in Common Health Scenarios 43 CHAPTER 1 44 Pain 45 Questions 1. Which postoperative client is manifesting the most serious negative effect of inadequate pain management? 1. Demonstrates continuous use of call bell related to unsatisfied needs and discomfort 2. Develops venous thromboembolism related to immobility caused by pain and discomfort 3. Refuses to participate in physical therapy because of fear of pain caused by exercises 4. Feels depressed about loss of function and hopeless about getting relief from pain 2. A client with chronic pain reports to the charge nurse that the other nurses have not been responding to requests for pain medication. What is the charge nurse's initial action? 1. Check the medication administration records for the past several days. 2. Ask the nurse educator to provide in-service training about pain management. 3. Perform a complete pain assessment on the client and take a pain history. 4. Have a conference with the staff nurses to assess their care of this client. 3. According to recent guidelines from the American Pain Society in collaboration with the American Society of Anesthesiologists, what are the priority pain management strategies that the nurse would expect to see in the pain management for postsurgical clients? Select all that apply. 1. Acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) for management of postoperative pain in adults and children without contraindications 2. Surgical site-specific peripheral regional anesthetic techniques in adults and children for procedures 3. Neuraxial (epidural) analgesia for major thoracic and abdominal procedures if the client has risk for cardiac complications or prolonged ileus 4. Multimodal therapy that could include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies 5. Long-acting oral opioids, especially in the immediate postoperative period, for continuous around-the-clock relief 6. Neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, or ketamine is recommended for postoperative pain 4. The home health nurse is interviewing an older client with a history of mild heart failure and rheumatoid arthritis. The client reports “feeling pretty good, 46 except for the pain and stiffness in my joints when I first get out of bed.” Which member of the health care team would be the most appropriate to aid in the client's report of pain? 1. Health care provider to review the dosage and frequency of pain medication 2. Physical therapist for evaluation of function and possible exercise therapy 3. Social worker to locate community resources for complementary therapy 4. Unlicensed assistive personnel to help client with a warm shower in the morning 5. Family members are encouraging the client to “tough out the pain” rather than risk drug addiction to opioids. The client is stoically abiding. The nurse recognizes that the sociocultural dimension of pain is the current priority for the client. Which question will the nurse ask? 1. “Where is the pain located, and does it radiate to other parts of your body?” 2. “How would you describe the pain, and how is it affecting you?” 3. “What do you believe about pain medication and drug addiction?” 4. “How is the pain affecting your activity level and your ability to function?” 6. A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-inflammatory drugs. Which medication will the nurse advocate for first? 1. Gabapentin 2. Corticosteroids 3. Hydromorphone 4. Lorazepam 7. Which client is most likely to receive opioids for extended periods of time? 1. A client with fibromyalgia 2. A client with phantom limb pain in the leg 3. A client with progressive pancreatic cancer 4. A client with trigeminal neuralgia 8. The nurse is caring for a postoperative client who reports pain. Based on recent evidence-based guidelines, which approach would be best? 1. Multimodal strategies 2. Standing orders by protocol 3. Intravenous patient-controlled analgesia (PCA) 4. Opioid dosage based on valid numerical scale 9. The charge nurse is reviewing the records of clients who were assigned to a newly graduated RN. The RN has correctly documented dose and time of medication, but there is no documentation regarding nonpharmaceutical 47 measures. What action should the charge nurse take first? 1. Make a note in the nurse's file and continue to observe clinical performance. 2. Refer the new nurse to the in-service education department. 3. Quiz the nurse about knowledge of pain management and pharmacology. 4. Give praise for documenting dose and time and discuss documentation deficits. 10. Which clients must be assigned to an experienced RN? Select all that apply. 1. Client who was in an automobile crash and sustained multiple injuries 2. Client with chronic back pain related to a workplace injury 3. Client who has returned from surgery and has a chest tube in place 4. Client with abdominal cramps related to food poisoning 5. Client with a severe headache of unknown origin 6. Client with chest pain who has a history of arteriosclerosis 11. In application of the principles of pain treatment, what is the first consideration? 1. Treatment is based on client goals. 2. A multidisciplinary approach is needed. 3. Client's perception of pain must be accepted. 4. Drug side effects must be prevented and managed. 12. The nurse is considering seeking clarification for several prescriptions of pain medication. Which client circumstance is the priority concern? 1. A 35-year-old opioid-naïve adult will receive a basal dose of morphine via IV patient-controlled analgesia (PCA). 2. A 65-year-old adult will be discharged with a prescription for nonsteroidal anti-inflammatory drugs (NSAIDS). 3. A 25-year-old adult is prescribed as needed intramuscular (IM) analgesic for pain. 4. A 45-year-old adult is taking oral fluids and foods has orders for IV morphine. 13. Which client has the most immediate need for IV access to deliver immediate analgesia with rapid titration? 1. Client who has sharp chest pain that increases with cough and shortness of breath 2. Client who reports excruciating lower back pain with hematuria 3. Client who is having an acute myocardial infarction with severe chest pain 4. Client who is having a severe migraine with an elevated blood pressure 14. When an analgesic is titrated to manage pain, what is the priority goal? 1. Titrate to the smallest dose that provides relief with the fewest side effects. 48 2. Titrate upward until the client is pain free or acceptable level is reached. 3. Titrate downward to prevent toxicity, overdose, and adverse effects. 4. Titrate to a dosage that is adequate to meet the client's subjective needs. 15. The health care provider prescribes 7 mg morphine IV as needed (PRN). The nursing student prepares the medication and shows the syringe (see figures below) to the nursing instructor. What should the nursing instructor do first? 49 50 1. Tell the student to review the provider's prescription before administering medication. 2. Waste the medication and tell the student that remediation is required for serious error. 3. Ask the student to demonstrate the calculations and steps required to prepare the dose. 4. Accompany the student to the client's room and observe as the medication is administered. 16. A client received as needed (PRN) morphine, lorazepam, and cyclobenzaprine. The unlicensed assistive personnel (UAP) reports that the client has a respiratory rate of 10 breaths/min. What is the priority action? 1. Call the health care provider to obtain an order for naloxone. 2. Assess the client's responsiveness and respiratory status. 3. Obtain a bag-valve mask and deliver breaths at 20 breaths/min. 4. Double-check the prescription to see which drugs were ordered. 17. The client is diagnosed by the emergency department health care provider (HCP) with an acute migraine. For which situation is it most important to have a discussion with the HCP before medication is prescribed? 1. The HCP is considering dexamethasone to prevent reoccurrence, and the client has type 2 diabetes. 2. The HCP is considering subcutaneous sumatriptan, and the client took ergotamine 3 hours ago. 3. The HCP is considering metoclopramide, and this is a first-time migraine for the client. 4. The HCP is considering prochlorperazine, and the client drove himself to the hospital. 18. Which client is at greatest risk for respiratory depression while receiving opioids for analgesia? 1. Older adult client with chronic pain related to joint immobility 2. Client with a heroin addiction and back pain 3. Young female client with advanced multiple myeloma 4. Opioid-naïve adolescent with an arm fracture and cystic fibrosis 19. A client is crying and grimacing but denies pain and refuses pain medication because “my brother is a drug addict and has ruined our lives.” What is the priority intervention for this client? 1. Encourage expression of fears and past experiences. 2. Provide accurate information about the use of pain medication. 3. Explain that addiction is unlikely among acute care clients. 51 4. Seek family assistance in resolving this problem. 20. A client's opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? 1. Fever 2. Nausea 3. Diaphoresis 4. Abdominal cramps 21. In the care of clients with pain and discomfort, which task is most appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Assisting the client with preparation of a sitz bath 2. Monitoring the client for signs of discomfort while ambulating 3. Coaching the client to deep breathe during painful procedures 4. Evaluating relief after applying a cold compress 22. The health care provider (HCP) has ordered a placebo for a client with chronic pain. The newly hired nurse feels very uncomfortable administering the medication. What is the first action that the new nurse should take? 1. Prepare the medication and hand it to the HCP. 2. Check the hospital policy regarding the use of a placebo. 3. Follow a personal code of ethics and refuse to participate. 4. Contact the charge nurse for advice and suggestions. 23. For a cognitively impaired client who cannot accurately report pain, what is the first action that the nurse should take? 1. Closely assess for nonverbal signs such as grimacing or rocking. 2. Obtain baseline behavioral indicators from family members. 3. Note the time of and client's response to the last dose of analgesic. 4. Give the maximum as needed (PRN) dose within the minimum time frame for relief. 24. The oncoming day shift nurse has received the shift report from the night nurse. The day shift nurse has done a quick check on all of the clients and has determined that all are stable and not in acute distress. Prioritize the order in which the oncoming nurse will care for the following clients, 1 being the first and 5 being the last. 1. Adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a continuous headache that is partially relieved by medication. 2. Older 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. 3. Middle-aged woman who is demanding and frequently calls for assistance. She was admitted for investigation of functional abdominal pain and is 52 scheduled for diagnostic testing this morning. 4. Older woman with advanced Alzheimer disease who requires total care for all activities of daily living. 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 facility. 5. Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. Today, the chest tube will be removed and the PCA pump will be discontinued. _____, _____, _____, _____, _____ 25. On the first day after surgery, a client receiving an analgesic via patient- controlled analgesia pump reports that the pain control is inadequate. What is the first action that the nurse should take? 1. Deliver the bolus dose per standing order. 2. Contact the health care provider (HCP) to increase the dose. 3. Try nonpharmacologic comfort measures. 4. Assess the pain for location, quality, and intensity. 26. The team is providing emergency care to a client who received an excessive dose of opioid pain medication. Which task is best to assign to the LPN/LVN? 1. Calling the health care provider (HCP) to report SBAR (situation, background, assessment, recommendation) 2. Giving naloxone and evaluating response to therapy 3. Monitoring the respiratory status for the first 30 minutes 4. Applying oxygen per nasal cannula as ordered 27. What is the best way to schedule medication for a client with constant pain? 1. As needed (PRN) at the client's request 2. Before painful procedures 3. IV bolus after pain assessment 4. Around-the-clock 28. 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. 1. Client who needs preoperative teaching about the patient-controlled analgesia pump 2. Client with a leg cast who needs neuro-circ checks and as needed (PRN) hydrocodone 3. Client who underwent a toe amputation and has diabetic neuropathic pain 4. Client with terminal cancer and severe pain who is refusing medication 5. Client who reports abdominal pain after being kicked, punched, and beaten 6. Client with arthritis who needs scheduled pain medications and heat applications 53 29. The nurse is caring for a client who had abdominal surgery yesterday. The client is restless and anxious and tells the nurse that the pain is getting worse despite the pain medication. Physical assessment findings include the following: temperature, 100.3°F (37.9°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. The nurse decides to notify the client's provider. Place the following report information in the correct order according to the SBAR (situation, background, assessment, recommendation) format. 1. “He is restless and anxious: temperature is 100.3°F (37.9°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.” 2. “He had abdominal surgery yesterday. He is on morphine via patient- controlled analgesia, but he says the pain is getting progressively worse.” 3. “I have tried to make him comfortable, and he is willing to wait until the next scheduled dose of pain medication, but I think his pain warrants evaluation.” 4. “Would you like to give me an order for any laboratory tests or additional therapies at this time?” 5. “Dr. S, this is Nurse J from Unit X. I’m calling about Mr. D, who is reporting severe abdominal pain.” _____, _____, _____, _____, _____ 30. Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? Select all that apply. 1. Anxious client with chronic pain who frequently uses the call button 2. Client on the second postoperative day who needs pain medication before dressing changes 3. Client with acquired immune deficiency syndrome who reports headache and abdominal and pleuritic chest pain 4. Client with chronic pain who is to be discharged with a new surgically implanted catheter 5. Client who is reporting pain at the site of a peripheral IV line 6. Client with a kidney stone who needs frequent as needed (PRN) pain medication 31. A client's family member comes to the nurse's station and says, “He needs more pain medicine. He is still having a lot of pain.” What is the nurse's best response? 1. “The health care provider (HCP) ordered the medicine to be given every 4 hours.” 2. “If medication is given too frequently, there are ill effects.” 3. “Please tell him that I will be right there to check on him.” 54 4. “Let's wait about 40 minutes. If there he still hurts, I’ll call the HCP.” 32. Pain disorder and depression have been diagnosed for a client. He reports chronic low back pain and states, “None of these doctors has done anything to help.” Which client statement is cause for greatest concern? 1. “I twisted my back last night, and now the pain is a lot worse.” 2. “I’m so sick of this pain. I think I’m going to find a way to end it.” 3. “Occasionally, I buy pain killers from a guy in my neighborhood.” 4. “I’m going to sue you and the doctor; you aren’t doing anything for me.” 33. A client has severe pain and bladder distention related to urinary retention and possible obstruction. An experienced unlicensed assistive personnel (UAP) states that she received training in indwelling catheter insertion at a previous job. What task can be delegated to this UAP? 1. Assessing the bladder distention and the pain associated with urinary retention 2. Inserting the indwelling catheter after verifying her knowledge of sterile technique 3. Evaluating the relief of pain and bladder distention after the catheter is inserted 4. Measuring the urine output after the catheter is inserted and obtaining a specimen 34. The nurse is caring for a young man with a history of substance abuse who had exploratory abdominal surgery 4 days ago for a knife wound. There is a prescription to discontinue the morphine via patient-controlled analgesia and to start oral pain medication. The client begs, “Please don’t stop the morphine. My pain is really a lot worse today than it was yesterday.” What is the best response? 1. “Let me stop the pump, and we can try oral pain medication to see if it relieves the pain.” 2. “I realize that you are scared of the pain, but we must try to wean you off the pump.” 3. “Show me where your pain is and describe how it feels compared with yesterday.” 4. “Let's take your vital signs; then I will discuss your concerns with the health care provider.” 35. The nurse is caring for a young client with type 1 diabetes who has sustained injuries when she tried to commit suicide by crashing her car. Her blood glucose (BG) level is 550 mg/dL (30.5 mmol/L), but she refuses insulin; however, she wants the pain medication. What is the best action? 1. Notify the charge nurse and make arrangements to transfer to intensive care. 2. Explain significance of BG and insulin and then call the health care 55 provider. 3. Withhold the pain medication until she agrees to accept the insulin. 4. Give her the pain medication and document the refusal of the insulin. 36. The nurse is working with a health care provider who prescribes opioid doses based on a specific pain intensity rating (dosing to the numbers). Which client circumstance is cause for greatest concern? 1. A 73-year-old frail female client with a history of chronic obstructive pulmonary disease is prescribed 4 mg IV morphine for pain of 1 to 3 on a scale of 0 to 10. 2. A 25-year-old postoperative male client with a history of opioid addiction is prescribed one tablet of oxycodone and acetaminophen for pain of 4 to 5 on a scale of 0 to 10. 3. A 33-year-old opioid-naïve female client who has a severe migraine headache is prescribed 5 mg IV morphine for pain of 7 to 8 on a scale of 0 to 10. 4. A 60-year-old male with a history of rheumatoid arthritis is prescribed one tablet of hydromorphone for pain of 5 to 6 on scale of 0 to 10. 37. The nurse recognizes that there are ethical considerations in helping clients to achieve relief from pain. Which nursing action is the best example of the principle of nonmaleficence? 1. Client seems excessively sedated but continues to ask for morphine, so the nurse conducts further assessment and seeks alternatives to opioid medication. 2. Client has no known disease disorders and no objective signs of poor health or injury, but reports severe pain, so nurse advocates for pain medicine. 3. Client is older, but he is mentally alert and demonstrates good judgment, so the nurse encourages the client to verbalize personal goals for pain management. 4. Client repeatedly refuses pain medication but shows grimacing and reluctance to move, so the nurse explains the benefits of taking pain medication. 38. The nurse is assessing a client who has been receiving opioid medication via patient-controlled analgesia. What is an early sign that alerts the nurse to a possible adverse opioid reaction? 1. Client reports shortness of breath. 2. Client is more difficult to arouse. 3. Client is more anxious and nervous. 4. Client reports pain is worsening. 39. The charge nurse of a long-term care facility is reviewing the methods and assessment tools that the staff nurses are using to assess pain. Which nurse is using the best method to assess pain? 56 1. Nurse A uses a behavioral assessment tool when the client is engaged in activities. 2. Nurse B asks a client who doesn’t speak English to point to the location of pain. 3. Nurse C uses the same numerical rating scale every day for the same client. 4. Nurse D asks the daughter of a confused client to describe the client's pain. 40. For which of these clients is IV morphine the first-line choice for pain management? 1. A 33-year-old intrapartum client needs pain relief for labor contractions. 2. A 24-year-old client reports severe headache related to being hit in the head. 3. A 56-year-old client reports breakthrough bone pain related to multiple myeloma. 4. A 73-year-old client reports chronic pain associated with hip replacement surgery. 41. The client is prescribed a fentanyl patch for persistent severe pain. Which client behavior most urgently requires correction? 1. Frequently likes to sit in the hot tub to reduce joint stiffness 2. Prefers to place the patch only on the upper anterior chest wall 3. Saves and reuses the old patches when he can’t afford new ones 4. Changes the patch every 4 days rather than the prescribed 72 hours 42. The home health nurse discovers that an older adult client has been sharing his pain medication with his daughter. Despite the nurse's warnings about the dangers of sharing, he states, “My daughter can’t afford to see a doctor or to buy medicine, so I must give her a few of my pain pills.” Which member of the health care team is the nurse most likely to consult first? 1. Health care provider to renew the prescription so that client has enough medicine 2. Pharmacist to monitor the frequency of the prescription refills 3. Social worker to help the family locate resources for health care 4. Home health aide to watch for inappropriate medication usage by family 43. For a postoperative client, the health care provider (HCP) prescribed multimodal therapy, which includes acetaminophen, nonsteroidal anti- inflammatory drugs, as needed (PRN) opioids, and nonpharmaceutical interventions. The client continuously asks for the PRN opioid, and the nurse suspects that the client may have a drug abuse problem. Which action by the nurse is best? 1. Administer acetaminophen and spend extra time with the client. 2. Explain that opioid medication is reserved for moderate to severe pain. 3. Give the opioid because client deserves relief and drug abuse is 57 unconfirmed. 4. Ask the HCP to validate suspicions of drug abuse and alter the opioid prescription. 44. An inexperienced graduate nurse is reviewing the medication administration record (MAR) for a client who has a patient-controlled analgesia (PCA) pump for pain management. The new nurse compares the MAR and the health care provider's (HCP’s) prescription, and both indicate that larger doses are prescribed at night compared with doses throughout the day. Which member of the health care team should the new nurse consult first? 1. Ask the client if he typically needs extra medication in the evening. 2. Ask the HCP to verify that the larger amount is the correct dose. 3. Ask the pharmacist to confirm the dosage on the original prescription. 4. Ask the charge nurse if this is a typical dosage for nighttime PCA. 58 Answer Key 1. Ans: 2 Inadequate pain management for postsurgical clients can affect quality of life, function, recovery, and postsurgical complication; thus, all the manifestations are examples of negative results. However, venous thromboembolism can lead to pulmonary embolism, and this is an immediate life-threatening concern. The nurse also needs to implement interventions to resolve unsatisfied needs, fear of pain, and hopelessness related to pain and function. Focus: Prioritization; Test Taking Tip: Use Maslow's hierarchy to identify priorities in caring for clients. Physiologic needs are the first concern. In this case, venous thromboembolism is the most serious physiologic outcome secondary to inadequate pain management. 2. Ans: 4 The charge nurse must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the re

Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX® Examination PDF

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