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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021)

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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 3 preview imageCopyright © 2021, Elsevier Inc. All rights reserved.iYOU’VE JUST PURCHASEDMORE THANA TEXTBOOK!REGISTER TODAY!PlaceStickerHereYou can now purchase Elsevier products on Evolve!Go to evolve.elsevier.com/shop to search and browse for products.2019v1.0Enhance your learning with Evolve Student Resources.These online study tools and exercises can help deepen yourunderstanding of textbook content so you can be moreprepared for class, perform better on exams, and succeedin your course.Activate the complete learning experience that comes with eachhttp://evolve.elsevier.com/LaCharity/prioritization/If your school uses its own Learning Management System, your resources may bedelivered on that platform. Consult with your instructor.has already been revealed, the code may have been used and cannotbe re-used for registration. To purchase a new code to access thesevaluable study resources, simply follow the link above.
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 6 preview imagePPPPPPattieeennt-Linda A. LaCharity, PhD, RNFormerly, Accelerated Program DirectorAssistant ProfessorCollege of NursingUniversity of CincinnatiCincinnati, OhioShirley M. Hosler, MSN, RNFormerly, Nursing InstructorSchool of NursingNational American UniversityAlbuquerque, New MexicoCandice K. Kumagai, MSN, RNFormerly, Clinical InstructorSchool of NursingUniversity of Texas at AustinAustin, TexasWith an introduction byRuth Hansten, MBA, PhD, RN, FACHEPrincipal Consultant and CEOHansten HealthcareSanta Rosa, California5thEDITIONPrioritization,Delegation,andAssignmentPractice Exercisesfor theNCLEX-RN®Examination
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 7 preview imageElsevier3251 Riverport LaneSt. Louis, Missouri 63043PRIORITIZATION, DELEGATION, AND ASSIGNMENT: PRACTICE EXERCISESFOR THE NCLEX-RN® EXAMINATION, FIFTH EDITIONISBN: 978- 0-323-68316-6Copyright © 2022 by Elsevier, Inc. All rights reserved.No part of this publication may be reproduced or transmitted in any form or by any means, electronic ormechanical, including photocopying, recording, or any information storage and retrieval system, withoutpermission in writing from the publisher. Details on how to seek permission, further information about thePublisher’s permissions policies and our arrangements with organizations such as the Copyright ClearanceCenter 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).NoticePractitioners and researchers must always rely on their own experience and knowledge in evaluatingand using any information, methods, compounds or experiments described herein. Because of rapidadvances in the medical sciences, in particular, independent verification of diagnoses and drug dosagesshould be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editorsor 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 ideascontained in the material herein.Previous editions copyrighted 2019, 2014, 2011, and 2006.Library of Congress Control Number: 2021936204Executive Content Strategist:Lee HendersonSenior Content Development Manager:Lisa NewtonSenior Content Development Specialist:Tina KaemmererPublishing Services Manager:Julie EddySenior Project Manager:Abigail BradberryDesign Direction:Margaret ReidPrinted in CanadaLast digit is the print number:987654321
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 8 preview imagevContributors and ReviewersCONTRIBUTORSMartha Barry, MS, RN, APN, CNMCertified Nurse MidwifeOB Faculty PracticeAdvocate Medical GroupChicago, Illinois;Adjunct Clinical InstructorCollege of NursingUniversity of Illinois at ChicagoChicago, IllinoisMary Tedesco-Schneck, PhD, RN, CPNPAssistant ProfessorSchool of NursingUniversity of MaineOrono, MaineREVIEWERSAmber Ballard, MSN, RNRegistered NurseEmergency DepartmentSparrow Health SystemLansing, MichiganAngela McConachie, DNP, MSN-FNP, RNDirector, BSN Program Accelerated OptionAssociate ProfessorGoldfarb School of Nursing at Barnes Jewish CollegeSt. Louis, Missouri
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 9 preview imageviPrefacePrioritization, Delegation, and Assignment: Practice Exercisesfor the NCLEX-RN®Examinationhas evolved since itsfirsteditionfromamedical-surgicalnursing–focusedtest preparation workbook to a resource that spans gen-eral nursing knowledge while emphasizing managementof care to assist students in preparing for the NCLEX®Examination. Our fifth edition includes many examplesof new question types that will be included in the forthcom-ing Next-Generation NCLEX® Examination (NGN). Asecond and equally important purpose of the book contin-ues to be assisting students, novice nurses, and seasonednurses in applying concepts of prioritization, delegation,and assignment to nursing practice in today’s patient caresettings.TO FACULTY AND OTHER USERSPatient care acuity continues to be higher than ever withthe essential added care of COVID-19 patients, whilestaffing shortages remain very real. Nurses must use allavailable patient care personnel and resources compe-tently and efficiently and be familiar with variations instate laws governing the practice of nursing, as well asdifferences in scopes of practice and facility-specific jobdescriptions. Nurses must also be aware of the differentskill and experience levels of the health care profession-als with whom they work on a daily basis. Which nursingactions can be assigned to an experienced versus a newgraduate RN or LPN/LVN? What forms of patient carecan the nurse delegate to assistive personnel (AP)? Whoshould help the postoperative patient who has had a totalhip replacement get out of bed and ambulate to the bath-room? Can the nurse ask APs such as nursing assistantsto check a patient’s oxygen saturation using pulse oxim-etry or check a diabetic patient’s glucose level? Whatreporting parameters should the nurse give to an LPN/LVN who is monitoring a patient after cardiac catheter-ization or to the AP checking patients’ vital signs? Whatpatient care interventions and actions should not be dele-gated by the nurse? The answers to these and many otherquestions should be much clearer after completion of theexercises in this book.Exercises in this book range from simple to complexand use various patient care scenarios. The purpose ofthe chapters and case studies is to encourage the studentor new graduate nurse to conceptualize using the skillsof prioritization, delegation, and assignment, as well assupervision in many different settings. Our goal is to makethese concepts tangible to our readers.The questions are written in NCLEX® Examinationformats, including new NGN styles to help faculty asthey teach student nurses how to prepare for licensureexamination. The chapters and case studies focus on realand hypothetical patient care situations to challengenurses and nursing students to develop the skills nec-essary to apply these concepts in practice. The exercisesare also useful to nurse educators as they discuss, teach,and test their students and nurses for understanding andapplication of these concepts in nursing programs, exam-ination preparations, and facility orientations. Correctanswers, along with in-depth rationales, are providedat the end of each chapter and case study to facilitatethe learning process, along with the focus/foci for eachitem. The faculty exercise keys include QSEN (Qualityand Safety Education for Nurses) categories, concepts,and cognitive levels for each question, as well as IPEC(Interprofessional Education Collaborative) competen-cies where appropriate.TO STUDENTSPrioritization, delegation, and assignment are essentialconcepts and skills for nursing practice. Our studentsand graduate nurses have repeatedly told us of their dif-ficulties with the application of these principles whentaking program exit and licensure examinations. Nursemanagers have told us many times that novice nursesand even some experienced nurses lack the expertise toeffectively and safely practice these skills in real-worldsettings.Although several excellent resources deal with theseissues, there is still a need for a book that incorporatesmanagementofthesecareconceptsintoreal-worldpractice scenarios. Our goal in writing the fifth editionofPrioritization,Delegation,andAssignment:PracticeExercises for the NCLEX-RN®Examinationis to providea resource that challenges nursing students, as well asnovice and experienced nurses, to develop the knowledgeand understanding necessary to effectively apply theseimportant nursing skills: examination preparation andreal-world practice. From the original focus on medical-surgical nursing, subsequent editions have expanded to
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 10 preview imagePREFACEviiinclude pediatrics, labor and delivery, psychiatric nursing,and long-term care as well as the role of the nurse in a vari-ety of nonacute care settings. Additionally, we have madechanges that reflect the current focus on evidence-basedbest practices, fundamentals of safe practice, and expan-sion of diabetes care. For the fifth edition, we respondedto requests for more questions, especially about medica-tions. New questions, including drug-related questions,have been added to each chapter. We also added questionsspecific to the needs of the lesbian, gay, bisexual, transgen-der, queer, intersexual, and asexual (LGBTQIA) commu-nity. New questions were added and revised throughoutthe book to broaden comprehension of key concepts andknowledge areas and to update current knowledge lev-els. Our fifth edition expands on all of these topics andincorporatesexamplesofNext-GenerationNCLEX®Examination (NGN) question formats to prepare stu-dents for the upcoming NCLEX® changes.Each new copy of the book comes with a fully interac-tive version of the book content, with scoring, on Evolve athttp://evolve.elsevier.com/LaCharity/prioritization.Thisinteractive version of the book helps to simulate the expe-rience of taking the NCLEX® Examination. Students canuse this interactive option to create multiple different testversions for practice and self-assessment.ACKNOWLEDGMENTSWe would like to thank the many people whose supportand assistance made the creation of the fifth edition ofthis book possible. Thanks to our families, colleagues, andfriends for listening, reading, encouraging, and makingsure we had the time to research, write, and review thisbook. We truly appreciate the expertise of our two con-tributing authors, Martha Barry (reproductive health) andMary Tedesco-Schneck (pediatrics), who each contributedan excellent chapter and case study related to their areasof expertise. Very special thanks to Ruth Hansten, whoseexpertise in the area of clinical prioritization, delegation,and assignment skills continues to keep us on track. Manythanks to the faculty reviewers, whose expertise helped uskeep the scenarios accurate and realistic. Finally, we wishto acknowledge our faculty, students, graduates, and read-ers who have taken the time to keep in touch and let usknow about their needs for additional assistance in devel-oping the skills to practice the arts of prioritization, del-egation, and assignment.Linda A. LaCharityCandice K. KumagaiShirley M. Hosler
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 11 preview imageviiiContentsPART 1INTRODUCTION, 1Guidelines for Prioritization, Delegation, andAssignment Decisions, 1PART 2PRIORITIZATION, DELEGATION, ANDASSIGNMENT IN COMMON HEALTHSCENARIOS, 11Chapter 1Pain, 11Chapter 2Cancer, 25Chapter 3Immunologic Problems, 38Chapter 4Fluid, Electrolyte, and Acid-Base BalanceProblems, 47Chapter 5Safety and Infection Control, 54Chapter 6Respiratory Problems, 63Chapter 7Cardiovascular Problems, 73Chapter 8Hematologic Problems, 84Chapter 9Neurologic Problems, 92Chapter 10Visual and Auditory Problems, 102Chapter 11Musculoskeletal Problems, 112Chapter 12Gastrointestinal and NutritionalProblems, 120Chapter 13Diabetes Mellitus, 133Chapter 14Other Endocrine Problems, 141Chapter 15Integumentary Problems, 149Chapter 16Renal and Urinary Problems, 157Chapter 17Reproductive Problems, 166Chapter 18Problems in Pregnancy and Childbearing, 176Chapter 19Pediatric Problems, 189Chapter 20Pharmacology, 201Chapter 21Emergencies and Disasters, 211Chapter 22Psychiatric/Mental Health Problems, 225Chapter 23NCLEX Next Generation, 237PART 3PRIORITIZATION, DELEGATION, ANDASSIGNMENT IN COMPLEX HEALTHSCENARIOS, 251Case Study 1Chest Pressure, Indigestion, and Nausea, 251Case Study 2Dyspnea and Shortness of Breath, 257Case Study 3Multiple Clients on a Medical-SurgicalUnit, 264Case Study 4Shortness of Breath, Edema, andDecreased Urine Output, 271Case Study 5Diabetic Ketoacidosis, 276Case Study 6Home Health, 283Case Study 7Spinal Cord Injury, 289Case Study 8Multiple Patients With Adrenal GlandDisorders, 294Case Study 9Multiple Clients With GastrointestinalProblems, 299Case Study 10Multiple Patients With Pain, 310Case Study 11Multiple Clients With Cancer, 320Case Study 12Gastrointestinal Bleeding, 330Case Study 13Head and Leg Trauma and Shock, 338Case Study 14Septic Shock, 345Case Study 15Heart Failure, 351Case Study 16Multiple Patients With PeripheralVascular Disease, 356Case Study 17Respiratory Difficulty After Surgery, 363Case Study 18Long-Term Care, 370Case Study 19Pediatric Clients in Clinic and AcuteCare Settings, 377Case Study 20Multiple Patients With Mental HealthDisorders, 386Case Study 21Childbearing, 397Illustration Credits,407
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 12 preview image1Copyright © 2022, Elsevier Inc. All rights reserved.IntroductionPART 1OUTCOMES FOCUSExpert nurses have discovered that the most success-ful method of approaching their practice is to maintain alaser-like focus on the outcomes that the patients and theirfamilies want to achieve. To attempt to prioritize, delegate,or assign care without understanding the patient’s preferredresults is like trying to put together a jigsaw puzzle with-out the top of the puzzle box that shows the puzzle picture.Not only does the puzzle player pick up random pieces thatdon’t fit well together, wasting time and increasing frustra-tion, but also the process of puzzle assembly is fraught withinefficiencies and wrong choices. In the same way, a nursewho scurries haphazardly without a plan, unsure of whatcould be the most important, life-saving task to be donefirst or which person should do which tasks for this group ofpatients, is not fulfilling his or her potential to be a channelfor healing.Let’s visit a change-of-shift report in which a groupof nurses receives information about two patients whoseblood pressure is plummeting at the same rate. How wouldone determine which nurse would be best to assign to carefor these patients, which patient needs to be seen first,and which tasks could be delegated to assistive person-nel (APs), if none of the nurses is aware of each patient’spreferred outcomes? Patient A is a young mother whohas been receiving chemotherapy for breast cancer; shehas been admitted this shift because of dehydration fromuncontrolled emesis. She is expecting to regain her nor-mally robust good health and watch her children gradu-ate from college. Everyone on the health care team wouldconcur with her long-term goals. Patient Z is an elderlygentleman, 92 years of age, whose wife recently died fromcomplicationsofrepeatedcerebrovasculareventsanddementia. Yesterday while in the emergency department(ED), he was given the diagnosis of acute myocardialinfarction and preexisting severe heart failure. He wouldlike to die and join his wife, has requested a “do not resus-citate” order, and is awaiting transfer to a hospice. Thesetwo patients share critical clinical data but require widelydifferent prioritization, delegation, and assignment. Asavvy charge RN would make the obvious decisions: toassign the most skilled RN to the young mother and toask APs to function in a supportive role to the primarycare RN.The elderly gentleman needs palliative care and wouldbe best cared for by an RN and care team with excellentpeople skills. Even a novice nursing assistant could be del-egated tasks to help keep Mr. Z and his family comfortableand emotionally supported. The big picture on the puzzlebox for these two patients ranges from long-term “robustgood health” requiring immediate emergency assessmentand treatment to “a supported and comfortable death”requiringtimelypalliativecare,includingsupportiveemotional and physical care. Without envisioning thesepatients’ pictures and knowing their preferred outcomes,the RNs cannot prioritize, delegate, or assign appropriately.There are many times in nursing practice, however, whencorrect choices are not so apparent. Patients in all care set-tings today are often complex, and many have preexistingcomorbidities that may stump the expert practitioners andclinical specialists planning their care. Care delivery sys-tems must flex on a moment’s notice as an AP arrives inplace of a scheduled LPN/LVN and agency, float, or travel-ing nurses fill vacancies, while new patients, waiting to beadmitted, accumulate in the ED or wait to be transferred toanother setting. APs arrive with varying educational prepa-ration and dissimilar levels of motivation and skill. Criticalthinking and complex clinical judgment are required fromthe minute the shift begins until the nurse clocks out.In this book, the authors have filled an educational needfor students and practicing nurses who wish to hone theirskills in prioritizing, assigning, and delegating. The scenar-ios and patient problems presented in this workbook arepractical, challenging, and complex learning tools. Qualityand Safety Education for Nurses (QSEN) competenciesare incorporated into this chapter and throughout the ques-tions to highlight patient-and family-centered care,qualityand safety improvement, and teamwork and collaborationconcepts and skills (QSEN Institute, 2019). Patient storieswill stimulate thought and discussion and help polish thehigher-order intellectual skills necessary to practice as asuccessful, safe, and effective nurse. The InterprofessionalCollaboration Competency Community and PopulationOriented Domains from the Interprofessional EducationCollaborative(IPEC)areappliedtothequestionsin this book as appropriate (Interprofessional EducationCollaborative,2016,https://ipecollaborative.org).Domains include Interprofessional Teamwork and Team-Based Practices, Interprofessional Teamwork Practices,Guidelines for Prioritization, Delegation,and Assignment DecisionsRuth Hansten, PhD, MBA, BSN, RN, FACHE
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 13 preview imageGuidelines for Prioritization, Delegation, and Assignment Decisions2Copyright © 2022, Elsevier Inc. All rights reserved.IntroductionPART 1Roles and Responsibilities for Collaborative Practice, andValues/Ethics for Interprofessional Practice.As reflected inthe IPEC sub-competencies, especially crucial for patientoutcomes is the role of the RN, armed with knowledge ofscopes of practice, successfully communicating with teammembers to delegate, assign, and supervise (IPEC, 2016).DEFINITION OF TERMSThe intellectual functions of prioritization, delegation,and assignment engage the nurse in projecting into thefuture from the present state. Thinking about what impactmight occur if competing decisions are chosen, weigh-ing options, and making split-second decisions, given theavailable data, is not an easy process. Unless resources interms of staffing, budget, time, or supplies are unlimited,nurses must relentlessly focus on choosing which issues orconcerns must take precedence.PrioritizationPrioritizationis defined as “ranking problems in order ofimportance” or “deciding which needs or problems requireimmediate action and which ones could tolerate a delayin action until a later time because they are not urgent”(Silvestri, 2018). Prioritization in a clinical setting is a pro-cess that involves clearly envisioning patient outcomes butalso includes predicting possible problems if another taskis performed first. One also must weigh potential futureevents if the task is not completed, the time it would taketo accomplish it, and the relationship of the tasks andoutcomes. New nurses often struggle with prioritizationbecause they have not yet worked with typical patientprogressions through care pathways and have not expe-rienced the complications that may emerge in associationwith a particular clinical condition. In short, knowing thepatient’spurpose for care, current clinical picture,andpicture of the outcome or resultis necessary to be ableto plan priorities. The part played by each team member isdesignated as the RN assigns or delegates. The “four Ps”—purpose, picture, plan, and part—become a guidepost forappropriately navigating these processes (Hansten, 2008a,2011, 2014b;Hansten and Jackson, 2009). The four Ps willbe referred to throughout this introduction because theseconcepts are the framework on which RNs base decisionsabout supporting patients and families toward their pre-ferred outcomes, whether RNs provide the care themselvesor work closely with assistive team members.Prioritization includes evaluating and weighing eachcompeting task or process using the following criteria(Hansten and Jackson, 2009, pp. 194–196):•Isitlifethreateningorpotentiallylifethreateningif the task is not done? Would another patient beendangered if this task is done now or the task is leftfor later?•Isthistaskorprocessessentialtopatientorstaffsafety?•Isthistaskorprocessessentialtothemedicalornursing plan of care?In each case, an understanding of the overall patientgoals and the context and setting is essential.1.In her book on critical thinking and clinical judg-ment, RosalindaAlfaro-Lefevre(2017)suggeststhree levels of priority setting: The first level isair-way,breathing,cardiac status and circulation, andvi-tal signs andlab values that could be life threatening(“ABCs plus V and L”).2.The second level is immediately subsequent to thefirst level and includes concerns such as mental sta-tus changes, untreated medical issues, acute pain,acute elimination problems, and imminent risks.3.The third level comprises health problems other thanthose at the first two levels, such as more long-termissues in health education, rest, coping, and so on(p. 171).Maslow’s hierarchy of needs can be used to prioritizefrom the most crucial survival needs to needs related tosafety and security, affiliation (love, relationships), self-esteem,andself-actualization(Alfaro-Lefevre,2017,p. 170).Delegation and AssignmentThe official definitions ofassignmenthave been alteredthrough ongoing dialogue among nursing leaders in variousstates and nursing organizations, and terminology distinc-tions such asobservationversusassessment, critical thinkingversusclinical reasoning,anddelegationversusassignmentcontinue to be discussed as nursing leaders attempt todescribe complex thinking processes that occur in variouslevels of nursing practice. Assignment has been definedas“the distribution of work that each staff member isresponsible for during a given work period”(AmericanNurses Association [ANA], Duffy & McCoy, 2014, p. 22).In 2016, the National Council of State Boards of Nursing(NCSBN) published the results of two expert panels toclarify thatassignmentincludes“the routine care, activi-ties, and procedures that are within the authorized scopeof practice of the RN or LPN/LVN or part of the routinefunctions of the UAP (Unlicensed Assistive Personnel)”(NCSBN, 2016b, pp. 6–7), and this definition was adoptedby the ANA in 2019 in a joint statement with the NCSBNwith the addition of the acronymAP (assistive personnel)(ANA & NCSBN 2019National Guidelines for NursingDelegation, p. 2).Delegationwas defined traditionally as“transferring to a competent individual the authority toperform a selected nursing task in a selected situation”(NCSBN, 1995), and similar definitions are used by somenurse practice statutes or regulations. Both the ANA andthe NCSBN describe delegation as“allowing a delegate
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 14 preview imageGuidelines for Prioritization, Delegation, and Assignment Decisions3Copyright © 2022, Elsevier Inc. All rights reserved.IntroductionPART 1to perform a specific nursing activity, skill, or procedurethat is beyond the delegatee’s traditional role and is notroutinely performed”(ANA & NCSBN 2019, p. 2).Nevertheless, the delegatee must be competent to performthat delegated task as a result of extra training and skillvalidation. The ANA specifies that delegation is a transferof responsibility or assignment of an activity while retain-ing the accountability for the outcome and the overall care(ANA, 2014;Duffy & McCoy, p. 22).Some state boards have argued that assignment isthe process of directing a nursing assistant to perform atask such as taking blood pressure, a task on which nurs-ing assistants are tested in the certified nursing assistantexamination and that would commonly appear in a jobdescription. Others contend that all nursing care is partof the RN scope of practice and therefore that such a taskwould be delegated rather than assigned. Other nursingleaders argue that only when a task is clearly within theRN’s scope of practice, and not included in the role of anAP, is the task delegated. Regardless of whether the alloca-tion of tasks to be done is based on assignment or delega-tion, in this book, assignment means the “work plan” andconnotes the nursing leadership role of human resourcesdeployment in a manner that most wisely promotes thepatient’s and family’s preferred outcome.Although states vary in their definitions of the functionsand processes in professional nursing practice, includingthat of delegation, the authors use the NCSBN and ANA’sdefinition, including the caveat present in the sentencefollowing the definition: delegation is “transferring to acompetent individual the authority to perform a selectednursing task in a selected situation. The nurse retains theaccountability for the delegation” (NCSBN, 1995, p. 2).Assignments are work plans that would include tasks thedelegatee would have been trained to do in their basiceducational program; the nurse “assigns” or distributeswork and also “delegates” nursing care as she or he worksthrough others. In advanced personnel roles, such as whencertified medication aides are taught to administer medi-cations or when certified medical assistants give injections,theNCSBN (2016)asserts that because of the extensiveresponsibilities involved, the employers and nurse lead-ers in the settings where certified medication aides areemployed, such as ambulatory care, skilled nursing homes,or home health settings, should regard these proceduresas being delegated and AP competencies must be assured(NCSBN, 2016b, p. 7). ANA designates these certified butunlicensed individuals as APs rather than UAPs (ANA &NSCBN 2019).The differences in definitions among statesand the differentiation between delegation and assignmentare perplexing to nurses. Because both processes are simi-lar in terms of the actions and thinking processes of theRN from a practical standpoint, this workbook will mergethe definitions to mean that RNs delegate or assign taskswhen they are allocating work to competent trained indi-viduals, keeping within each state’s scope of practice, rules,and organizational job descriptions. Whether assigning ordelegating, the RN is accountable for the total nursing careof the patient and for making choices about which compe-tent person is permitted to perform each task successfully.Whether the RN is delegating or assigning, depending ontheir state regulations, the expert RN will not ask a teammember to perform a task that is beyond the RN’s ownscope of practice or job description, or a task outside ofany person’s competencies. In all cases the choices made toallocate work must prioritize which allocation of work isoptimal for the patient’s safe and effective care (Hansten2020, in Kelly Vana and Tazbir).Delegation or Assignment and SupervisionThe definitions of delegation and assignment offer someimportant clues to nursing practice and to the compositionof an effective patient care team. The person who makesthe decision to ask a person to do something (a task orassignment) must know that the chosen person is com-petent to perform that task. The RN selects the particulartask, given his or her knowledge of the individual patient’scondition and that particular circumstance. Because of thenurse’s preparation, knowledge, and skill, the RN choosesto render judgments of this kind and stands by the choicesmade. According to licensure and statute, the nurse is obli-gated to delegate or assign based on the unique situation,patients, and personnel involved and to provide ongoingfollow-up.SupervisionWhenever nurses delegate or assign, they must also super-vise.Supervisionis defined by the NCSBN as“the pro-vision of guidance and direction, oversight, evaluation,and follow up by the licensed nurse for accomplishmentof a nursing task delegated to nursing assistive person-nel”and by the ANA as“the active process of directing,guiding, and influencing the outcome of an individual’sperformance of a task”(ANA, 2014;Duffy & McCoy,p. 23). Each state may use a different explanation, suchasWashingtonState’ssupervisiondefinition:“initialdirection…periodic inspection…and the authority torequire corrective action”(Washington AdministrativeCode 246-840-010 Definitions,https://app.leg.wa.gov/wac/default.aspx?cite=246-840-010). The act of delegatingor assigning is just the beginning of the RN’s responsibil-ity. As for the accountability of the delegatees (or peoplegiven the task duty), these individuals are accountablefor a) accepting only the responsibilities that they knowthey are competent to complete, b) maintaining their skillproficiency, c) pursuing ongoing communication with theteam’s leader, and d) completing and documenting the taskappropriately (ANA and NCSBN, 2019, p. 9). For exam-ple, nursing assistants who are unprepared or untrained tocomplete a task should say as much when asked and canthen decline to perform that particular duty. In such a situ-ation, the RN would determine whether to allocate time
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 15 preview imageGuidelines for Prioritization, Delegation, and Assignment Decisions4Copyright © 2022, Elsevier Inc. All rights reserved.IntroductionPART 1to train the AP and review the skill as it is learned, to del-egate the task to another competent person, to do it herselfor himself, or to make arrangements for later skill train-ing. The RN’s job continues throughout the performanceand results of task completion, evaluation of the care, andongoing feedback to the delegatees.Scope of Practice for RNs, LPNs/LVNs, and APsHeretofore this text has discussed national recommendationsfor definitions. National trends suggest that nursing is mov-ing toward standardized licensure through mutual recogni-tion compacts and multistate licensure, and as of April 2019,31 states had adopted the nurse license compact allowinga nurse in a member state to possess one state’s license andpractice in another member state, with several states pend-ing (NCSBN, 2019a). Standardized and multistate licensuresupports electronic practice and promotes improved practiceflexibility. Each RN must know his or her own state’s regu-lations, however. Definitions still differ from state to state,as do regulations about the tasks that nursing assistants orother APs are allowed to perform in various settings.For example, APs are delegated tasks for which theyhave been trained and that they are currently competentto perform for stable patients in uncomplicated circum-stances; these are routine, simple, repetitive, commonactivities not requiring nursing judgment, such as activi-ties of daily living, hygiene, feeding, and ambulation. Somestates have generated statutes and/or rules that list specifictasks that can or cannot be delegated. Nevertheless, trendsindicate that more tasks will be delegated as research sup-ports such delegation through evidence of positive out-comes. Acute care hospital nursing assistants have nothistorically been authorized to administer medications.In some states, specially certified medication assistantsadminister oral medications in the community (grouphomes) and in some long-term care facilities, althoughthere is substantial variability in state-designated certi-fied nursing assistant (CNA) duties (McMullen etal.,2015). More states are employing specially trained nurs-ing assistants as CMAs (certified medication assistants)or MA-Cs (medication assistants-certified) to administerroutine, nonparenteral medications in long-term care orcommunity settings with training as recommended by theNCSBN’s Model Curriculum (NCSBN, 2016, p. 7). Forover a decade, Washington state has altered the statute andrelated administrative codes to allow trained nursing assis-tants in home or community-based settings, such as board-ing homes and adult family homes, to administer insulinif the patient is an appropriate candidate (in a stable andpredictable condition) and if the nursing assistant has beenappropriately trained and supervised for the first 4 weeksof performing this task (Revised Code of Washington,2012). Nationally, consistency of state regulation of APmedication administration in residential care and adultday-care settings has been stated to be inadequate toensure RN oversight of APs (Carder & O’Keeffe, 2016).This research finding should serve as a caution for all prac-ticing in these settings. Other studies of nursing homesand assisted living facilities show evidence of role confu-sion among RNs, LPN/LVNs, and APs (Mueller et al.,2018;Dyck & Novotny, 2018). In ambulatory care set-tings, medical assistants (MAs) are being used extensively,supervised by RNs, LPNs (depending on the state), physi-cians, or other providers, and nurses are cautioned to knowboth the state nursing and medical regulations. In somecases (Maryland, for example), a physician could delegateperipheral IV initiation to an MA with on-site supervision,but in some states an LPN is prohibited from this sametask (Maningo and Panthofer, 2018, p.2).In all states, nursing judgment is used to delegate tasksthat fall within, but never exceed, the nurse’s legal scopeof practice, and an RN always makes decisions based onthe individual patient situation. An RN may decide notto delegate the task of feeding a patient if the patient isdysphagic and the nursing assistant is not familiar withfeeding techniques. A “Lessons Learned from Litigation”article in theAmerican Journal of Nursingin May 2014describes the hazards of improper RN assignment, del-egation, and supervision of patient feeding, resulting in apatient’s death and licensure sanctions (Brous, 2014).The scope of practice for LPNs or LVNs also differsfrom state to state and is continually evolving. For exam-ple, in Texas, LPNs are prohibited from delegating nurs-ing tasks; only RNs are allowed to delegate (Texas Boardof Nursing, 2019,http://www.bon.texas.gov/faq_delegation.asp#t6), whereas in Washington state an LPN coulddelegate to nursing assistants in some settings (listed ashospitals, nursing homes, clinics, and ambulatory surgerycenters) (Washington Nursing Care Quality AssuranceCommission2019,https://www.doh.wa.gov/Portals/1/Documents/6000/NCAO13.pdf).Althoughpracticingnurses know that LPNs often review a patient’s conditionand perform data-gathering tasks such as observation andauscultation, RNs remain accountable for the total assess-ment of a patient, including the synthesis and analysis ofreported and reviewed information to lead care planningbased on the nursing diagnosis. In their periodic review ofactual practice by LPNs, the NCSBN found that assign-ing client care or related tasks to other LPNs or APs wasranked sixth in frequency, with monitoring activities ofAPs ranked seventh (NCSBN, 2019, p. 156). IV therapyand administration of blood products or total parenteralnutrition by LPNs/LVNs also vary widely. Even in stateswhere regulations allow LPNs/LVNs to administer bloodproducts, a given health care organization’s policies or jobdescriptions may limit practice and place additional safe-guards because of the life-threatening risk involved in theadministration of blood products and other medications.The RN must review the agency’s job descriptions as wellas the state regulations because either is changeable.LPN/LVN practice continues to evolve, and in anystate, tasks to support the assessment, planning, interven-tion, and evaluation phases of the nursing process can be
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 16 preview imageGuidelines for Prioritization, Delegation, and Assignment Decisions5Copyright © 2022, Elsevier Inc. All rights reserved.IntroductionPART 1allocated. When it is clear that a task could possibly bedelegated to a skilled delegatee according to your state’sscope of practice rules and is not prohibited by the organi-zation policies, the principles of delegation and/or assign-ment remain the same. The totality of the nursing processremains the responsibility of the RN.Also,the total nursingcare of the patient rests squarely on the RN’s shoulders, nomatter which competent and skilled individual is asked toperform care activities. To obtain more information aboutthe statute and rules in a given state and to access decisiontrees and other helpful aides to delegation and supervi-sion, visit the NCSBN website athttp://www.ncsbn.org.The state practice act for each state is linked at that site.ASSIGNMENT PROCESSIn current hospital environments, the process of assigningor creating a work plan is dependent on who is available,present, and accounted for and what their roles and compe-tencies are for each shift. Assignment has been understoodto be the “work plan” or“the distribution of work thateach staff member is responsible for during a given workperiod”(American Nurses Association (ANA),Duffy &McCoy, 2014, p. 22). Classical care delivery models onceknown astotal patient carehave been transformed into acombination of team, functional, and primary care nursing,depending on the projected patient outcomes, the presentpatient state, and the available staff. Assignments must becreated with knowledge of the following issues (Hanstenand Jackson, 2009, pp. 207–208,Hansten, 2020in KellyVana and Tazbir):•Howcomplexisthepatient’srequiredcare?•Whatarethedynamicsofthepatient’sstatusandtheir stability?•Howcomplexistheassessmentandongoingevaluation?•Whatkindofinfectioncontrolisnecessary?•Arethereanyindividualsafetyprecautions?•Istherespecialtechnologyinvolvedinthecare,andwho is skilled in its use?•Howmuchsupervisionandoversightwillbeneededbased on the staff ’s numbers and expertise?•HowavailablearethesupervisingRNs?•Howwillthephysicallocationofpatientsaffectthetime and availability of care?•Cancontinuityofcarebemaintained?•Arethereanypersonalreasonstoallocatedutiesforaparticular patient, or are there nurse or patient pref-erences that should be taken into account? Factorssuch as staff difficulties with a particular diagnosis,patient preferences for an employee’s care on a previ-ous admission, or a staff member’s need for a particu-lar learning experience will be taken into account.•Isthereanacuityratingsystemthatwillhelpdistrib-ute care based on a point or number system?Formoreinformationoncaredeliverymodali-ties, refer to the texts byHansten and Jackson (2009)or access Hansten’s webinars related to assignment andcare delivery models athttp://learning.hansten.com/andAlfaro-LeFevre (2017)listed in the References section.Whichever type of care delivery plan is chosen for eachparticular shift or within your practice arena, the rela-tionship with the patient and the results that the patientwants to achieve must be foremost, followed by the plac-ing together of the right pieces in the form of compe-tent team members, to compose the complete picture(Hansten, 2019).DELEGATION AND ASSIGNMENT: THE FIVERIGHTSAs you contemplate the questions in this workbook, youcan use mnemonic devices to order your thinking pro-cess, such as the “five rights.” The right task is assigned tothe right person in the right circumstances. The RN thenoffers the right direction and communication and the rightsupervision and evaluation (Hansten and Jackson, 2009,pp. 205–206;NCSBN, 1995, pp. 2–3;Hansten, 2014a,p. 70;NCSBN, 2016b, p. 8;ANA & NCSBN, 2019, p. 4).Right TaskReturningtotheguidepostsfornavigatingcare, thepatient’s four Ps (purpose, picture, plan, and part), the righttask is a task that, in the nurse’s best judgment, is one thatcan be safely delegated for this patient, given the patient’scurrent condition (picture) and future preferred outcomes(purpose, picture), if the nurse has a competent willingindividual available to perform it. Although the RN maybelieve that he or she personally would be the best personto accomplish this task, the nurse must prioritize the bestuse of his or her time given a myriad of factors, such as:What other tasks and processes must I do because I amthe only RN on this team? Which tasks can be delegatedbased on state regulations and my thorough knowledge ofjob descriptions here in this facility? How skilled are thepersonnel working here today? Who else could be avail-able to help if necessary?InitsdraftmodellanguagefornursingAPs, theNCSBN lists criteria for determining nursing activitiesthat can be delegated. The following are recommendedfor the nurse’s consideration. It should be kept in mindthat the nursing process and nursing judgment cannot bedelegated.•Knowledgeandskillsofthedelegatee•Verificationofclinicalcompetencebytheemployer•Stabilityofthepatient’scondition•Servicesettingvariablessuchasavailableresources(including the nurse’s accessibility) and methods ofcommunication, complexity and frequency of care, andproximity and numbers of patients relative to staff
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 17 preview imageGuidelines for Prioritization, Delegation, and Assignment Decisions6Copyright © 2022, Elsevier Inc. All rights reserved.IntroductionPART 1APs are not to be allocated the duties of the nursingprocess of assessment (except gathering data), nursingdiagnosis, planning, implementation (except those tasksdelegated/assigned), or evaluation. Professional clinicaljudgment or reasoning and decisionmaking related tothe manner in which the RN makes sense of the patient’sdata and clinical progress cannot be delegated or assigned(ANA & NCSBN, 2019, p. 3).Right CircumstancesRecall the importance of the context in clinical decisionmaking. Not only do rules and regulations adjust based onthe area of practice (i.e.,home health care,acute care,schools,ambulatory clinics, long-term care), but patient conditionsand the preferred patient results must also be considered. Ifinformation is not available, a best judgment must be made.Often RNs must balance the need to know as much as pos-sible and the time available to obtain the information. Theinstability of patients immediately postoperatively or in theintensive care unit (ICU) means that a student nurse willhave to be closely supervised and partnered with an experi-enced RN. The questions in this workbook give direction asto context and offer hints to the circumstances.For example, in long-term care skilled nursing facilities,LPNs/LVNs often function as “team leaders” with ongo-ing care planning and oversight by a smaller number ofon-site RNs. Some EDs use paramedics, who may be reg-ulated by the state emergency system statutes, in differentroles in hospitals. Medical clinics often employ “medicalassistants” who function under the direction and supervi-sion of physicians, other providers, and RNs. Communitygroup homes, assisted living facilities, and other healthcare providers beyond acute care hospitals seek to createsafe and effective care delivery systems for the growingnumber of older adults. Whatever the setting or circum-stance, the nurse is accountable to know the specific lawsand regulations that apply.Right PersonLicensure, Certification, and Role DescriptionOne of the most commonly voiced concerns during work-shops with staff nurses across the nation is, “How can Itrust the delegatees?” Knowing the licensure, role, andpreparation of each member of the team is the first step indetermining competency. What tasks does a patient caretechnician (PCT) perform in this facility? What is the roleof an LPN/LVN? Are different levels of LPN/LVN des-ignated here (LPN I or II)? Nearly 100 different titles forAPs have been developed in care settings across the coun-try.To effectively assign or delegate, the RN must know therole descriptions of co-workers as well as his or her own.Strengths and WeaknessesThe personal strengths and weaknesses of everyday teammembersarenomystery. Theirskillsarediscoveredthrough practice, positive and negative experiences, andan ever-present but unreliable rumor mill. An expertRN helps create better team results by using strengths inassigning personnel to make the most of their gifts. Themost compassionate team members will be assigned workwith the hospice patient and his or her family. The super-vising nurse helps identify performance flaws and developsstaff by providing judicious use of learning assignments.For example, a novice nursing assistant can be partneredwith an experienced oncology RN during the assistant’sfirst experiences with a terminally ill patient.When working with students, float nurses, or other tem-porary personnel, nurses sometimes forget that the assign-ing RN has the duty to determine competency. Askingpersonnel about their previous experiences and about theirunderstanding of the work duties, as well as pairing themwith a strong unit staff member, is as essential as provid-ing the ongoing support and supervision needed through-out the shift. If your mother was an ICU patient and hernurse was an inexperienced float from the rehabilitationunit, what level of leadership and direction would thatnurse need from an experienced ICU RN? Many hospitalsdelegate only tasks and not overall patient responsibility,a functional form of assignment, to temporary personnelwho are unfamiliar with the clinical area.Right Direction and CommunicationNow that the right staff member is being delegated theright task for each particular situation and setting, teammembers must find out what they need to do and howthe tasks must be done. Relaying instructions about theplan for the shift or even for a specific task is not as simpleas it seems. Some RNs believe that a written assignmentboard provides enough information to proceed because“everyone knows his or her job,” but others spend copiousamounts of time giving overly detailed directions to boredstaff. The “four Cs” of initial direction will help clarify thesalient points of this process (Hansten and Jackson, 2009,pp. 287–288;Hansten, 2021in Zerwekh and Garneau,p. 316). Instructions and ongoing direction must beclear, concise, correct, and complete.Clear communication is information that is understoodby the listener. An ambiguous question such as: “Can youget the new patient?” is not helpful when there are severalnew patients and returning surgical patients, and “getting”could mean transporting, admitting, or taking full respon-sibility for the care of the patient. Asking the delegatee torestate the instructions and work plan can be helpful todetermine whether the communication is clear.Concise statements are those that give enough but nottoo much additional information. The student nurse whomerely wants to know how to turn on the chemical stripanalyzer machine does not need a full treatise on the tran-sit of potassium and glucose through the cell membrane.Too much or irrelevant information confuses the listenerand wastes precious time.
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 18 preview imageGuidelines for Prioritization, Delegation, and Assignment Decisions7Copyright © 2022, Elsevier Inc. All rights reserved.IntroductionPART 1Correct communication is that which is accurate andis aligned to rules, regulations, or job descriptions. Are theroom number, patient name, and other identifiers correct?Are there two patients with similar last names? Can thistask be delegated to this individual? Correct communi-cation is not cloudy or confusing (Hansten and Jackson,2009, pp. 287–288;Hansten, 2021inZerwekhandGarneau, p. 318).Complete communication leaves no room for doubt onthe part of supervisor or delegatees. Staff members oftensay, “I would do whatever the RNs want if they wouldjust tell me what they want me to do and how to do it.”Incomplete communication wins the top prize for creat-ing team strife and substandard work. Assuming that staff“know” what to do and how to do it, along with whatinformation to report and when, creates havoc, rework, andfrustration for patients and staff alike. Each staff membershould have in mind a clear map or plan for the day, whatto do and why, and what and when to report to the teamleader. Parameters for reporting and the results that shouldbe expected are often left in the team leader’s brain ratherthan being discussed and spelled out in sufficient detail.RNs are accountable for clear, concise, correct, and com-plete initial and ongoing direction.Right Supervision and EvaluationAfterprioritization,assignment,anddelegationhavebeenconsidered, determined, andcommunicated, theRN remains accountable for the total care of the patientsthroughout the tour of duty. Recall that the definition ofsupervisionincludes not only initial direction but also that“supervision is the active process of directing, guiding, andinfluencing the outcome of an individual’s performance ofa task. Similarly, NCSBN defines supervision as “the provi-sion of guidance or direction, oversight, evaluation and fol-low-up by the licensed nurse for the accomplishment of adelegated nursing task by assistive personnel” (ANA, 2014,in Duffy and McCoy,p. 23). RNs may not actually per-form each task of care, but they must oversee the ongoingprogress and results obtained, reviewing staff performance.Evaluation of the care provided, and adequate documenta-tion of the tasks and outcomes, must be included in thislast of the five rights. On a typical unit in an acute carefacility, assisted living, or long-term care setting, the RNcan ensure optimal performance as the RN begins the shiftby holding a short “second report” meeting with APs, out-lining the day’s plan and the plan for each patient, andgiving initial direction at that time. Subsequent short teamupdate or “checkpoint” meetings should be held beforeand after breaks and meals and before the end of the shift(Hansten, 2005, 2008a, 2008b, 2019). During each shortupdate, feedback is often offered, and plans are altered.The last checkpoint presents all team members with anopportunity to give feedback to one another using thestep-by-step feedback process (Hansten, 2008a, pp. 79–84;Hansten, 2021, in Zerweck and Garneau, pp. 301–302).This step is often called the “debriefing” checkpoint orhuddle, in which the team’s processes are also examined. Inambulatory care settings, this checkpoint may be towardthe end of each patient’s visit or the end of the shift; inhome health care, these conversations are often conductedon a weekly basis. Questions such as, “What would yourecommend I do differently if we worked together tomor-row on the same group of patients?” and “What can we dobetter as a team to help us navigate the patients towardtheir preferred results?” will help the team function moreeffectively in the future.1.The team member’s input should be solicitedfirst.“I noted that the vital signs for the first fourpatients aren’t yet on the electronic record. Do youknow what’s been done?” rather than “WHY haven’tthose vital signs been recorded yet?” At the end ofthe shift, the questions might be global, as in “Howdid we do today?” “What would you do differently ifwe had it to do over?” “What should I do differentlytomorrow?”2.Credit should be given for all that has been accom-plished.“Oh, so you have the vital signs done, butthey aren’t recorded? Great, I’m so glad they are doneso I can find out about Ms. Johnson’s temperaturebefore I call Dr. Smith.”“You did a fantastic job withcleaning Mr. Hu after his incontinence episodes;his family is very appreciative of our respect for hisdignity.”3.Observations or concerns should be offered.“Thevital signs are routinely recorded on the electron-ic medical record (EMR) before patients are sentfor surgery and procedures and before the doctor’sround so that we can see the big picture of patients’progress before they leave the unit and to make surethey are stable for their procedures.” Or, “I think Ishould have assigned another RN to Ms. A. I hadno idea that your mother recently died of breastcancer.”4.The delegatee should be asked for ideas on how toresolve the issue.“What are your thoughts on howyou could order your work to get the vital signs onthe EMR before 8:30 AM?” Or, “What would youlike to do with your work plan for tomorrow? Shouldwe change Ms. A.’s team?”5.A course of action and plan for the future shouldbe agreed upon.“That sounds great. Practice useof the handheld computers today before you leave,and that should resolve the issue. When we work to-gether tomorrow, let me know whether that resolvesthe time issue for recording; if not, we will go to an-other plan.” Or, “If you still feel that you want to staywith this assignment tomorrow after you’ve slept onit, we will keep it as is. If not, please let me knowfirst thing tomorrow morning when you awaken sowe can change all the assignments before the staffarrive.”
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 19 preview imageGuidelines for Prioritization, Delegation, and Assignment Decisions8Copyright © 2022, Elsevier Inc. All rights reserved.IntroductionPART 1PRACTICE BASED ON RESEARCH EVIDENCERationale for Maximizing Nursing Leadership Skills atthe Point of CareIf the skills presented in this book are used to save livesby providing care prioritized to attend to the most unsta-ble patients first, optimally delegated to be deliveredby the right personnel, and assigned using appropriatelanguage with the most motivational and conscientioussupervisory follow-up, then clinical outcomes should beoptimal and work satisfaction should flourish. Solid cor-relational research evidence has been lacking related to“the best use of personnel to multiply the RN’s ability toremain vigilant over patient progress and avoid failuresto rescue, but common sense would advise that betterdelegation and supervision skills would prevent errorsand omissions as well as unobserved patient decline”(Hansten, 2008b,2019).In an era of value-based purchasing and health carereimbursement based on clinical results with linkagesfor care along the continuum from site to site, an RN’saccountability has irrevocably moved beyond task orienta-tion to leadership practices that ensure better outcomesfor patients, families, and populations. The necessity ofefficiency and effectiveness in health care means that RNsmust delegate and supervise appropriately so that all tasksthat can be safely assigned to APs are completed flawlessly.Patient safety experts have linked interpersonal commu-nication errors and teamwork communication gaps asmajor sources of medical errors and The Joint Commissionassociated these as root causes of 70% or more of seriousreportable events (Grant, 2016, p. 11). Severe events thatharm patients (sentinel events) can occur through inad-equate hand-offs between caregivers and along the healthcare continuum as patients are transferred (The JointCommission, 2017).Nurses are accountable for processes as well as out-comes measures so that insurers will reimburse health careorganizations. If hospital-acquired conditions occur, suchas pressure injuries falls with injury, and some infections,reimbursement for the care of that condition will be nega-tively impacted.•Nurseshavebeenreportedtospendmorethanhalftheir time on tasks other than patient care, includingsearching for team members and internal communi-cations (Voalte Special Report, 2013). Shift reportat the bedside, along with better initial direction anda plan for supervision during the day, all ultimatelydecrease time wasted when nurses must attempt toconnect with team members when delegation andassignment processes do not include the five rights.At one facility in the Midwest, shift hand-offs werereduced to 10 to 15 minutes per shift per RN as aresult of a planned approach to initial direction andcare planning, which thus saved each RN 30 to45 minutes per day (Hansten, 2008a, p. 34). Betteruse of nursing and AP time can result in more time tocare for patients, giving RNs the opportunity to teachpatients self-care or to maintain functional status.•Whennursesdidnotappropriatelyimplementthefive rights of delegation and supervision with assis-tive personnel, errors occurred that potentially couldhave been avoided with better RN leadership behav-iors. Early research about the impact of supervisionon errors showed that about 14% of task errors orcare omissions related to teamwork were because oflack of RN direction or communication, and approxi-mately 12% of the issues stemmed from lack of su-pervision or follow-up (Standing, Anthony, & Hertz,2001). Lack of communication among staff membershas been an international issue leading to care thatis not completed appropriately (Diab & Ebrahim,2019). Errors can result in uncompensated condi-tions or readmissions; unhappy patients and provid-ers; disgruntled health care purchasers; and a disloyal,anxious patient community (Hansten, 2019).•Teamworkandjobsatisfactionhavebeenfoundtobe negatively correlated with over-delegation and ahierarchical relationship between nurses and assis-tive personnel (Kalisch 2015, p. 266–227), but of-fering feedback effectively has been shown to im-prove team thinking and performance (Mizne, D.,2018,https://www.15five.com/blog/7-employee-engagement-trends-2018/).Workplaceinjuries,expensive employee turnover, and patient safety havebeen linked with employee morale. Daily or weeklyfeedback has been requested by a majority of teamsand this could be achieved by excellent delegation,assignment, and supervision shift routines (McNee,2017,https://www.mcknights.com/blogs/guest-columns/nurse-morale-and-its-impact-on-ltc/).Best practices for deployment of personnel includea connection to patient outcomes, which can oc-cur during initial direction and debriefing supervi-sion checkpoints (Hansten, 2021in LaCharity andGarneau).•Unplannedreadmissionstoacutecarewithin30 days of discharge are linked to potential penal-tiesandreducedreimbursement. InadequateRNinitial direction and supervision of APs can lead tomissed mobilization, hydration, and nutrition of pa-tients, therebydischargingdeconditionedpatients,and can be traced to ED visits and subsequent read-missions. Reimbursement bundling for specific carepathways such as total joint replacements or acuteexacerbation of chronic obstructive pulmonary diseaserequires that team communication and RN supervisionof coworkers along the full continuum must be seam-less from ambulatory care to acute care, rehabilitation,and home settings (Kalisch, 2015;Hansten, 2019).•Aspublicqualitytransparencyandcompetitionforbest value become the norm, ineffective delegationhas been a significant source of missed care, such
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 20 preview imageGuidelines for Prioritization, Delegation, and Assignment Decisions9Copyright © 2022, Elsevier Inc. All rights reserved.IntroductionPART 1as lack of care planning, lack of turning or ambula-tion, delayed or missed nutrition, and lack of hygiene(Bittner etal., 2011;Kalisch, 2015, pp. 266–270).These care omissions can be contributing factorsfor the occurrence of unreimbursed “never events”(events that should never occur), such as pressure ul-cers and pneumonia, as well as prolonged lengths ofstay. Other nurse-sensitive quality indicators such ascatheter-associated urinary tract infections could becorrelated to omitted perineal hygiene and inatten-tion to discontinuation of catheters. Useful modelsthat link delegation with care omissions and ensu-ing care hazards such as thrombosis, pressure inju-ries, constipation, and infection, combined with aSwiss Cheese Safety Model showing defensive stepsagainst health care–acquired conditions and errorsthrough excellence in RN leadership, can be ac-cessed in the August 2014Nurse Leaderathttps://doi.org/10.1016/j.mnl.2013.10.007(Hansten, 2014a;Hansten, 2020in Kelly Vana and Tazbir).•Inperioperativenursing,suchomissionsaslackofwarming, oral care, head elevation and deep breath-ing, can lead to postoperative pneumonia and lack ofoptimal healing (Ralph and Viljoen, 2018). Many ofthese interventions could be delegated or assigned.Evidence does indicate that appropriate nursing judg-ment in prioritization, delegation, and supervision can savetime and improve communication and thereby improvecare, patient safety, clinical outcomes, and job satisfaction,potentially saving patient-days and absenteeism and recruit-ment costs. Patient satisfaction, staff satisfaction, and clinicalresults decline when nursing care is poor. Potential reim-bursement is lost, patients and families suffer, and the healthof our communities decays when RNs do not assume theleadership necessary to work effectively with all team mem-bers (Bittner et al., 2011,Kalisch, 2015,Hansten, 2019).PRINCIPLES FOR IMPLEMENTATION OFPRIORITIZATION, DELEGATION, ANDASSIGNMENTReturn to our goalposts of the four Ps (purpose, picture,plan, and part) as a framework as you answer the questionsin this workbook and further develop your own expertiseand recall the following principles:•TheRNshouldalwaysstartwiththepatient’sandfamily’s preferred outcomes in mind. The RN is firstclear about the patient’s purpose for accessing careand his or her picture for a successful outcome.•TheRNshouldrefertotheapplicablestatenursingpractice statute and rules as well as the organization’sjob descriptions for current information about rolesand responsibilities of RNs, LPNs/LVNs, and APs.(These are the roles or the parts that people play.)•Studentnurses,novices,floatnurses,andotherinfre-quent workers also require variable levels of supervi-sion, guidance, or support (The workers’ abilities androles become a piece of the plan.) (NCSBN, 2016b).•TheRNisaccountablefornursingjudgmentdeci-sions and for ongoing supervision of any care that isdelegated or assigned.•TheRNcannotdelegatethenursingprocess(inparticular the assessment, planning, and evaluationphases) or clinical judgment to a non-RN. Some in-terventions or data-gathering activities may be del-egated based on the circumstances.•TheRNmustknowasmuchaspracticalaboutthepatients and their conditions, as well as the skills andcompetency of team members, to prioritize, delegate,and assign. Decisions must be specifically individual-ized to the patient, the delegatees, and the situation.•Inaclinicalsituation,everythingisfluidandshift-ing. No priority, assignment, or delegation is writtenindelibly and cannot be altered. The RN in charge ofa unit, a team, or one patient is accountable to choosethe best course to achieve the patient’s and family’spreferred results.Best wishes in completing this workbook! The authorsinvite you to use the questions as an exercise in assem-bling the pieces to the puzzle that will become a picture ofhealth-promoting practice.REFERENCESAlfaro-Lefevre R:Critical thinking, clinical reasoning, and clinicaljudgment: a practical approach, ed 6, St Louis, 2017, Saunders.American Nurses Association. National Guidelines for NursingDelegation. Effective 4/1/2019, by ANA Board of Directors/NCSBN Board of Directors. Retrieved April 12, 2019 fromhttps://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/joint-statement-on-delegation-by-ANA-and-NCSBN/[file available to membersonly athttps://www.nursingworld.org/globalassets/practiceandpolicy/nursing-excellence/ana-position-statements-secure/ana-ncsbn-joint-statement-on-delegation.pdf,accessedApril12,2019.]American Nurses Association, Duffy M, Fields McCoy S:DelegationandYOU:when to delegate and to whom, Silver Springs, MD,2015. ANA.Bittner N, Gravlin G, Hansten R, Kalisch B: Unraveling careomissions,J Nurs Adm41(12):510–512, 2011.Brous E: Lessons learned from litigation: the case of BernardTravaglini,Am J Nurs(114):5:68–70, 2014 5.Carder PC,O’Keeffe J: State regulation of medication administrationby unlicensed assistive personnel in residential care and adult dayservices settings,Res Gerontol Nurs7:1–14, 2016.Diab G, Ebrahim R: Factors leading to missed nursing care amongnurses at selected hospitals,Am J Nurs Res7 (2): 136-147, 2019.DyckM,NovotnyN:Exploringreportedpracticehabitsofregistered nurses and licensed practical nurses at Illinois nursinghomes,J Nurs Reg9 (2): 18-30, 2018.Grant V: Sharpening your legal IQ: safeguarding your license,Viewpoint38(3):10–12, 2016.
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 21 preview imageGuidelines for Prioritization, Delegation, and Assignment Decisions10Copyright © 2022, Elsevier Inc. All rights reserved.IntroductionPART 1Hansten R: Relationship and results-oriented healthcare: evaluatethe basics,J Nurs Adm35(12):522–524, 2005.Hansten R: Leadership at the point of care: nursing delegation,2011. Retrieved May 31, 2012, fromhttp://www.MyFreeCE.com.Hansten R:Relationship and results oriented healthcare™ planningand implementation manual, Port Ludlow, Wash, 2008a, HanstenHealthcare PLLC.Hansten R: Why nurses still must learn to delegate,Nurse Leader6(5):19–26, 2008b.Hansten R, Jackson M:Clinical delegation skills: a handbook forprofessional practice, ed 4, Sudbury, Mass, 2009, Jones & Bartlett.Hansten R:The master coach manual for the relationship & resultsoriented healthcare program, Port Ludlow, Wash, 2014b, HanstenHealthcare PLLC.Hansten R: Coach as chief correlator of tasks to results throughdelegation skill and teamwork development,Nurse Leader, 12(4):69–73, 2014a.HanstenR:AnotherLookatRNleadershipskilllevelandpatientoutcomes.LinkedInPulse.RetrievedApril21,2019fromhttps://www.linkedin.com/pulse/another-look-rn-leadership-skill-level-patient-hansten-rn-mba-phd.Hansten R: Delegation, assignment, and supervision in Kelly VanaP & Tazbir J, ed.Nursing leadership and management, 4th Ed.Hoboken, NJ. 2020 (in press), Wiley.Hansten R: Delegation in the clinical setting. In Zerwekh J, GarneauA, editors:Nursing today: transitions and trends, ed 10, St Louis,2021, Elsevier.InterprofessionalEducationCollaborative.Corecompetenciesforinterprofessionalcollaborativepractice:2016update.Washington, DC: Interprofessional Education Collaborative.Retrieved April 16, 2019 from780E69ED19E2B3A5&disposition=0&alloworigin=1.Kalisch B:Errors of Omission: How missed nursing care imperilspatents. Silver Springs, MD., 2015, ANA.Kalisch B: Missed nursing care,J Nurs Care Qual21(4):306–313,2006.Maningo MJ, Panthofer N: Appropriate delegation in an ambulatorycare setting AAACNViewpoint40 (1): 1-2, 2018.McMullen TL, Resnick B, Chin-Hansen J, et al: Certified nurseaide scope of practice: state-by-state differences in allowabledelegated activities,J Am Med Dir Assoc6(1):20–24, 2015.MizneD.7fascinatingemployeeengagementtrendsfor2018.15Five.com.RetrievedApril21,2019fromhttps://www.15five.com/blog/7-employee-engagement-trends-2018/, pp. 1-11, 2018.McNee B. Nurse morale and its impact on LTC, McKnights Long-Term Care News, June 28, 2017. Retrieved April 21, 2019fromhttps://www.mcknights.com/blogs/guest-columns/nurse-morale-and-its-impact-on-ltc/, pp. 1-2, 2017Mueller C,Vogelsmeier A,Anderson R,McConnell E,& Corazzini K.Interchangeability of licensed nurses in nursing homes: perspectiveof directors of nursing.The End to End Journal, 1, 1-27, 2018.National Council of State Boards of Nursing:Delegation: conceptsand decision-making process,Issues December:1–4, 1995.National Council of State Boards of Nursing. 2018 LPN/VNPractice Analysis: Linking the NCLEX-PN Examination toPractice. NCSBN Research Brief vol. 75: March 2019. RetrievedApril 17, 2019 fromhttps://www.ncsbn.org/13443.htm.m 2019.National Council of State Boards of Nursing: National guidelinesfor nursing delegation.J Nurs Reg7(1):5–14, 2016b. AccessedApril 21, 2019 athttps://www.ncsbn.org/NCSBN_Delegation_Guidelines.pdfNational Council of State Boards of Nursing: Participating states inthe nurse licensure compact implementation. Retrieved April 17,2019 fromhttps://www.ncsbn.org/compacts.htm., 2019.QSEN Institute: QSEN Institute Website: QSEN Competencies.Retrieved April 19, 2019 fromhttp://qsen.org/competencies/graduate-ksas/.Ralph N, Viljoen B. Fundamentals of missed care: Implications forthe perioperative environment,ACORN Journal of PerioperativeNursing31 (3): Spring, 3-4, 2018.Revised Code of Washington, Title 18, Chapter 18.79, Section18.79.260, Registered nurse—activities allowed—delegation oftasks. Retrieved April 18, 2019 fromhttp://apps.leg.wa.gov/RCW/default.aspx?cite=18.79.260.Silvestri L, Silvestri A. Saunders 2018-2019 Strategies for TestSuccess: p. 63. St Louis, 2018, Elsevier.Standing T, Anthony M, Hertz J: Nurses’ narratives of outcomesafterdelegationtounlicensedassistivepersonnel,OutcomesManag Nurs Pract5(1):18–23, 2001.TheJointCommission.Inadequatehand-offcommunication.Sentinel Event Alert Issue58, September 12, 2017.Texas Board of Nursing 2013. “Frequently Asked Questions:Delegation:” P. 2 (1-7), 2013. Retrieved April 21, 2019 fromhttp://www.bon.texas.gov/faq_delegation.asp#t6.Voalte:SpecialReporttop10clinicalcommunicationtrends2013pp.1-16.RetrievedApril24,2019fromhttps://www.voalte.com/press-releases/new-survey-finds-hospital-nurses-spend-half-shift-tasks-patient-care.Washington State Administrative Code 246-840-010 Definitions.Retrieved April 19, 2019 fromhttps://app.leg.wa.gov/wac/default.aspx?cite=246-840-010, 2019.Washington State Department of Health Nursing Care QualityAssurance Commission Advisory Opinion 13.01 2019 RegisteredNurse and Licensed Practical Nurse Scope of Practice, 3-8-2019:p. 4 (1-12). Retrieved April 25, 2019 fromhttps://www.doh.wa.gov/Portals/1/Documents/6000/NCAO13.pdf.RECOMMENDED RESOURCESAlfaro-Lefevre R:Critical thinking, clinical reasoning, and clinicaljudgment: a practical approach, ed 6, St Louis, 2017, Saunders.Hansten R:The master coach manual for the relationship & resultsoriented healthcare program, Port Ludlow, Wash, 2014, HanstenHealthcare PLLC.Hansten R:Relationship and results oriented healthcare™ planningand implementation manual, Port Ludlow, Wash, 2008, HanstenHealthcare PLLC.Hansten R, Jackson M:Clinical delegation skills: a handbook forprofessional practice, ed 4, Sudbury, Mass, 2009, Jones & Bartlett.Hansten R. Coach as chief correlator of tasks to results through dele-gation skill and teamwork development.Nurse Leader12(4): 69–73.HanstenHealthcarePLLCwebsite,http://www.Hansten.comorhttp://www.RROHC.com.Checkfornewdelegation/supervisionresources,onlinedelegation,andassignmenteducation modules at http://learning.Hansten.com/.NationalCouncilofStateBoardsofNursingwebsite,http://www.ncsbn.org.Containslinkstostateboardsandabundant resources relating to delegation and supervision. Alsodownload the ANA and NCSBN Joint Statement on Delegation.The decision trees and step-by-step process through the fiverights are exceptionally clear and a great review to prepare forthe NCLEX athttps://www.ncsbn.org/NCSBN_Delegation_Guidelines.pdfandhttps://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 22 preview imageCopyright © 2022, Elsevier Inc. All rights reserved.11Prioritization, Delegation, and Assignment in CommonHealth ScenariosPART 1CHAPTER 1PainQuestions1.Basedon the principles of pain treatment, which con-sideration comesfirst?1.Treatment is based on patient goals.2.A multidisciplinary approach is needed.3.Patient’s perception of pain must be accepted.4.Drug side effects must be prevented and managed.2.AccordingtoCentersforDiseaseControlandPrevention (CDC) guidelines for opioid use for pa-tients with chronic pain, which actions are part of thenurse’s responsibility related to the current opioid cri-sis?Select all that apply.1.Recognize that negative attitudes toward substanceabusers is a barrier to patient compliance.2.Accesselectronicprescriptiondrugmonitor-ing program whenever patients receive an opioidprescription.3.Learn to recognize the signs and symptoms of opi-oid overdose and the proper use of naloxone.4.Use a tone of voice and facial expression that con-vey acceptance and understanding of patients whoare addicted.5.Report health care providers who fail to safely pre-scribe opioids according to the guidelines.3.On the first day after surgery, a patient who is on apatient-controlled analgesia pump reports that thepain control is inadequate. Which action would thenurse takefirst?1.Deliver the bolus dose per standing order.2.Contact the health care provider (HCP) to increasethe dose.3.Try nonpharmacologic comfort measures.4.Assess the pain for location, quality, and intensity.4.The team is providing emergency care to a patientwho received an excessive dose of opioid pain medica-tion. Which task isbestto assign to the LPN/LVN?1.Calling the health care provider (HCP) to re-portSBAR(situation, background, assessment,recommendation)2.Giving naloxone and evaluating response to therapy3.Monitoring the respiratory status for the first 30minutes4.Applying oxygen per nasal cannula as ordered5.What is thebestway to schedule medication for apatient with constant pain?1.As needed at the patient’s request2.Before painful procedures3.IV bolus after pain assessment4.Around-the-clock6.Which patient is atgreatestrisk for respiratory de-pression when receiving opioids for analgesia?1.Older adult patient with chronic pain related tojoint immobility2.Patient with a heroin addiction and back pain3.Youngfemalepatientwithadvancedmultiplemyeloma4.Opioid-naïve adolescent with an arm fracture andcystic fibrosis7.The home health nurse is interviewing an older patientwith a history of rheumatoid arthritis who reports“feeling pretty good, except for the pain and stiffnessin my joints when I first get out of bed.” Which mem-ber of the health care team would be notified to aid inthe patient’s pain?1.Health care provider to review the dosage and fre-quency of pain medication2.Physical therapist for evaluation of function andpossible exercise therapy3.Social worker to locate community resources forcomplementary therapy4.Home health aide to help patient with a warmshower in the morning8.A patient with diabetic neuropathy reports a burn-ing, electrical-type pain in the lower extremities thatis worse at night and not responding to nonsteroidalantiinflammatory drugs. Which medication will thenurse advocate forfirst?1.Gabapentin
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 23 preview imageCHAPTeR1Pain12Copyright © 2022, Elsevier Inc. All rights reserved.Answer Key for this chapter begins on p. 19Common Health ScenariosPART 22.Corticosteroids3.Hydromorphone4.Lorazepam9.When an analgesic is titrated to manage pain, what istheprioritygoal?1.Titrate to the smallest dose that provides reliefwith the fewest side effects.2.Titrate upward until the patient is pain free or anacceptable level is reached.3.Titrate downward to prevent toxicity, overdose, andadverse effects.4.Titrate to a dosage that is adequate to meet thepatient’s subjective needs.10.According to recent guidelines from the AmericanPain Society in collaboration with the AmericanSociety of Anesthesiologists, which pain managementstrategies areimportantfor postsurgical patients?Select all that apply.1.Acetaminophenand/ornonsteroidalanti-inflammatory drugs (NSAIDs) for management ofpostoperative pain in adults and children withoutcontraindications2.Surgical site–specific peripheral regional anesthetictechniques in adults and children for procedures3.Neuraxial (epidural) analgesia for major thoracicand abdominal procedures if the patient has riskfor cardiac complications or prolonged ileus4.Multimodal therapy that could include opioidsand nonopioid therapies, regional anesthetic tech-niques, and nonpharmacologic therapies5.IV administration of opioids, rather than oral opi-oids, for postoperative analgesia6.Pain specialists to manage the postoperative painfor all surgical patients11.When a patient stoically abides with his parent’s en-couragement to “tough out the pain” rather than riskan addiction to opioids, the nurse recognizes that thesociocultural dimension of pain is the currentpriorityfor the patient. Which question will the nurseask?1.“Where is the pain located, and does it radiate toother parts of your body?”2.“How would you describe the pain, and how is itaffecting you?”3.“What do you believe about pain medication anddrug addiction?”4.“How is the pain affecting your activity level andyour ability to function?”12.Which patient ismostlikely to receive opioids for ex-tended periods of time?1.A patient with fibromyalgia2.A patient with phantom limb pain in the leg3.A patient with progressive pancreatic cancer4.A patient with trigeminal neuralgia13.The nurse is caring for a postoperative patient who re-ports pain. Based on recent evidence-based guidelines,which approach would bebest?1.Multimodal strategies2.Standing orders by protocol3.Intravenous patient-controlled analgesia (PCA)4.Opioid dosage based on valid numerical scale14.A newly graduated RN has correctly documenteddose and time of medication, but there is no docu-mentation regarding nonpharmaceutical measures.What action should the charge nurse takefirst?1.Make a note in the nurse’s file and continue to ob-serve clinical performance.2.Refer the new nurse to the in-service educationdepartment.3.Quiz the nurse about knowledge of pain manage-ment and pharmacology.4.Give praise for documenting dose and time anddiscuss documentation deficits.15.Which patients must be assigned to an experiencedRN?Select all that apply.1.Patient who was in an automobile crash and sus-tained multiple injuries2.Patient with chronic back pain related to a work-place injury3.Patient who has returned from surgery and has achest tube in place4.Patient with abdominal cramps related to foodpoisoning5.Patient with a severe headache of unknown origin6.Patient with chest pain who has a history ofarteriosclerosis16.Whichpostoperativepatientismanifestingthemostseriousnegativeeffectofinadequatepainmanagement?1.Demonstrates continuous use of call bell related tounsatisfied needs and discomfort2.Develops venous thromboembolism because of im-mobility caused by pain and discomfort3.Refuses to participate in physical therapy becauseof fear of pain caused by exercises4.Feels depressed about loss of function and hopelessabout getting relief from pain17.The nurse is considering seeking clarification for sev-eral prescriptions of pain medication. Which patientcircumstance is thepriorityconcern?1.A 35-year-old opioid-naïve adult will receive abasal dose of morphine via IV patient-controlledanalgesia.
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 24 preview imageCHAPTeR1Pain13Copyright © 2022, Elsevier Inc. All rights reserved.Answer Key for this chapter begins on p. 19Common Health ScenariosPART 22.A 65-year-old adult will be discharged with a pre-scription for nonsteroidal antiinflammatory drugs(NSAIDs).3.A 25-year-old adult is prescribed as-needed intra-muscular (IM) analgesic for pain.4.A 45-year-old adult is taking oral fluids and foodsand has orders for IV morphine.18.Which patient has themostimmediate need for IVaccess to deliver analgesia with rapid titration?1.Patient who has sharp chest pain that increaseswith cough and shortness of breath2.Patient who reports excruciating lower back painwith hematuria3.Patient who is having an acute myocardial infarc-tion with severe chest pain4.Patient who is having a severe migraine with anelevated blood pressure19.A patient received as-needed morphine, lorazepam,and cyclobenzaprine. The unlicensed assistive person-nel (AP) reports that the patient has a respiratory rateof 10 breaths/min. Which action is thepriority?1.Call the health care provider to obtain a prescrip-tion for naloxone.2.Assess the patient’s responsiveness and respiratorystatus.3.Obtain a bag-valve mask and deliver breaths at 20breaths/min.4.Double-check the prescription to see which drugswere prescribed.20.The patient is diagnosed with an acute migraine by thehealth care provider (HCP). For which situation is itmostimportant to have a discussion with the HCPbefore medication is prescribed?1.The HCP is considering dexamethasone, and thepatient has type 2 diabetes.2.The HCP is considering subcutaneous sumatriptan,and the patient took ergotamine 3 hours ago.3.The HCP is considering valproate sodium, andthe patient recently started birth control pills.4.The HCP is considering prochlorperazine, and thepatient drove himself to the hospital.21.A patient is crying and grimacing but denies pain andrefuses opioid medication because “my brother is adrug addict and has ruined our lives.” Which inter-vention is thepriorityfor this patient?1.Encourage expression of fears and past experiences.2.Respect the patient’s wishes and use nonpharma-cologic therapies.3.Explain that addiction is unlikely when opioids areused for acute pain.4.Seek family assistance to support the prescribedtherapy.22.A patient’s opioid therapy is being tapered off, and thenurse is watchful for signs of withdrawal. What is oneof thefirstsigns of withdrawal?1.Fever2.Nausea3.Diaphoresis4.Abdominal cramps23.In the care of patients with pain and discomfort,which task ismostappropriate to delegate to unli-censed assistive personnel (AP)?1.Assisting the patient with preparation of a sitzbath2.Monitoring the patient for signs of discomfortwhile ambulating3.Coaching the patient to deep breathe during pain-ful procedures4.Evaluating relief after applying a cold compress24.The health care provider (HCP) prescribed a placebofor a patient with chronic pain. The newly hired nursefeels very uncomfortable administering a placebo.Which action would the new nurse takefirst?1.Prepare the prescribed placebo and hand it to theHCP.2.Check the hospital policy regarding the use of aplacebo.3.Follow a personal code of ethics and refuse toparticipate.4.Contactthechargenurseforadviceandsuggestions.25.For a cognitively impaired patient who cannot accu-rately report pain, which action would the nurse takefirst?1.Closely assess for nonverbal signs such as grimac-ing or rocking.2.Obtain baseline behavioral indicators from familymembers.3.Note the time of and patient’s response to the lastdose of analgesic.4.Give the maximum as-needed dose within theminimum time frame for relief.26.A patient with chronic pain reports to the chargenurse that the other nurses have not been respondingto requests for pain medication. What is the chargenurse’sinitialaction?1.Check the medication administration records forthe past several days.2.Ask the nurse educator to provide in-service train-ing about pain management.3.Perform a complete pain assessment on the patientand take a pain history.4.Have a conference with the staff nurses to assesstheir care of this patient.
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 25 preview imageCHAPTeR1Pain14Copyright © 2022, Elsevier Inc. All rights reserved.Answer Key for this chapter begins on p. 19Common Health ScenariosPART 227.According to recent guidelines from the Center forDisease Control and Prevention for prescribing/us-ing opioid medication for chronic pain, which pre-scriptions would the nurse question because of theincreased risk for opioid overdose?Select all thatapply.1.Extended-release/long-acting (ER/LA) transder-mal fentanyl for a patient with fibromyalgia2.Time-scheduled ER/LA oxycodone for a patientwith chronic low back pain3.As-needed (PRN) morphine for arthritis pain foran elderly patient with sleep apnea4.90 morphine milligram equivalents/day for a pa-tient who has a hip fracture5.ER/LA methadone PRN for a patient with head-ache pain6.Patient-controlled analgesia (PCA) morphine for apatient with postsurgical abdominal pain28.Which patients can be appropriately assigned to anewly graduated RN who has recently completed ori-entation?Select all that apply.1.Anxious patient with chronic pain who frequentlyuses the call button2.Patient on the second postoperative day who needspain medication before dressing changes3.Patient with acquired immune deficiency syndromewho reports headache and abdominal and pleuriticchest pain4.Patient with chronic pain who is to be dischargedwith a new surgically implanted catheter5.Patient who is reporting pain at the site of a pe-ripheral IV line6.Patient with a kidney stone who needs frequentas-needed pain medication29.A patient’s spouse comes to the nurse’s station andsays, “He needs more pain medicine. He is still havinga lot of pain.” Which response isbest?1.“The medication is prescribed to be given every 4hours.”2.“If medication is given too frequently, there are illeffects.”3.“Please tell him that I will be right there to checkon him.”4.“Let’s wait 40 minutes. If he still hurts, I’ll call thehealth care provider.”30.A patient with pain disorder and depression haschronic low back pain. He states, “None of these doc-tors has done anything to help.” Which patient state-ment is cause forgreatestconcern?1.“I twisted my back last night, and now the pain is alot worse.”2.“I’m so sick of this pain. I think I’m going to find away to end it.”3.“Occasionally, I buy pain killers from a guy in myneighborhood.”4.“I’m going to sue you and the doctor; you aren’t do-ing anything for me.”31.A patient has severe pain and bladder distention re-lated to urinary retention and possible obstruction;insertion of an indwelling catheter is prescribed. Anexperienced unlicensed assistive personnel (AP) statesthat she is trained to do this procedure. Which taskcan be delegated to this AP?1.Assessing the bladder distention and the pain as-sociated with urinary retention2.Inserting the indwelling catheter after verifying herknowledge of sterile technique3.Evaluating the relief of pain and bladder distentionafter the catheter is inserted4.Measuring the urine output after the catheter is in-serted and obtaining a specimen32.The nurse is caring for a young man with a historyof substance abuse who had exploratory abdominalsurgery 4 days ago for a knife wound. There is a pre-scription to discontinue the morphine via patient-controlled analgesia and to start oral pain medication.The patient begs, “Please don’t stop the morphine. Mypain is really a lot worse today than it was yesterday.”Which response isbest?1.“Let me stop the pump; we can try oral pain medi-cation to see if it gives relief.”2.“I realize that you are scared of the pain, but wemust try to wean you off the pump.”3.“Show me where your pain is and describe how itfeels compared with yesterday.”4.“Let’s take your vital signs; then I will call thehealth care provider.”33.The nurse is working with a health care providerwho prescribes opioid doses based on a specif-ic pain intensity rating (dosing to the numbers).Which patient circumstance is cause forgreatestconcern?1.A 73-year-old frail female patient with a historyof chronic obstructive pulmonary disease is pre-scribed 4 mg IV morphine for pain of 1 to 3 on ascale of 0 to 10.2.A 25-year-old postoperative male patient with ahistory of opioid addiction is prescribed one tabletof oxycodone and acetaminophen for pain of 4 to 5on a scale of 0 to 10.3.A 33-year-old opioid-naïve female patient who hasa severe migraine headache is prescribed 5 mg IVmorphine for pain of 7 to 8 on a scale of 0 to 10.4.A 60-year-old male with a history of rheumatoidarthritis is prescribed one tablet of hydromorphonefor pain of 5 to 6 on scale of 0 to 10.
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 26 preview imageCHAPTeR1Pain15Copyright © 2022, Elsevier Inc. All rights reserved.Answer Key for this chapter begins on p. 19Common Health ScenariosPART 234.Which nursing action is thebestexample of the prin-ciple of nonmaleficence as an ethical consideration inpain management?1.Patient seems excessively sedated but continuesto ask for morphine, so the nurse conducts fur-ther assessment and seeks alternatives to opioidmedication.2.Patient has no known disease disorders and noobjective signs of poor health or injury, but re-ports severe pain, so nurse advocates for painmedicine.3.Patient is older, but he is mentally alert and dem-onstrates good judgment, so the nurse encouragesthe patient to verbalize personal goals for painmanagement.4.Patientrepeatedlyrefusespainmedicationbutshowsgrimacingandreluctancetomove,sothe nurse explains the benefits of taking painmedication.35.The nurse is assessing a patient who has been receivingopioid medication via patient-controlled analgesia.Whichearlysign alerts the nurse to a possible adverseopioid reaction?1.Patient reports shortness of breath.2.Patient is more difficult to arouse.3.Patient is more anxious and nervous.4.Patient reports pain is worsening.36.The charge nurse of a long-term care facility is review-ing the methods and assessment tools that are beingused to assess the residents’ pain. Which nurse is usingthebestmethod to assess pain?1.Nurse A uses a behavioral assessment tool whenthe resident is engaged in activities.2.Nurse B asks a resident who doesn’t speak Englishto point to the location of pain.3.Nurse C uses the same numerical rating scale everyday for the same resident.4.Nurse D asks the daughter of a confused patient todescribe the resident’s pain.37.For which of these patients is IV morphine the first-line choice for pain management?1.A 33-year-old intrapartum patient needs pain re-lief for labor contractions.2.A 24-year-old patient reports severe headache re-lated to being hit in the head.3.A 56-year-old patient reports breakthrough bonepain related to multiple myeloma.4.A 73-year-old patient reports chronic pain associ-ated with hip replacement surgery.38.The patient is prescribed a fentanyl patch for persis-tent severe pain. Which patient behaviormostur-gently requires correction?1.Frequently likes to sit in the hot tub to reduce jointstiffness2.Prefers to place the patch only on the upper ante-rior chest wall3.Saves and reuses the old patches when he can’t af-ford new ones4.Changes the patch every 4 days rather than theprescribed 72 hours39.The home health nurse discovers that an older adultpatient has been sharing his pain medication with hisdaughter. He acknowledges the dangers of sharing,but states, “My daughter can’t afford to see a doctoror buy medicine, so I must give her a few of my painpills.” Which member of the health care team wouldthe nurse consultfirst?1.Health care provider to renew the prescription sothat the patient has enough medicine2.Pharmacist to monitor the frequency of the pre-scription refills3.Social worker to help the family locate resourcesfor health care4.Home health aide to watch for inappropriate med-ication usage by family40.For a postoperative patient, the health care provider(HCP) prescribed multimodal therapy, which includesacetaminophen, nonsteroidal antiinflammatory drugs,as-needed (PRN) opioids, and nonpharmaceutical in-terventions. The patient continuously asks for the PRNopioid, and the nurse suspects that the patient may havea drug abuse problem.Which action by the nurse isbest?1.Administer acetaminophen and spend extra timewith the patient.2.Explain that opioid medication is reserved formoderate to severe pain.3.Give the opioid because the patient deserves reliefand drug abuse is unconfirmed.4.Ask the HCP to validate suspicions of drug abuseand alter the opioid prescription.41.An inexperienced new nurse compares the medication ad-ministration record (MAR) and the health care provider’s(HCP’s) prescription for a patient who has a patient-controlled analgesia (PCA) pump for pain management.Both the MAR and prescription indicate that larger dosesare prescribed at night compared with doses throughoutthe day. Who would the new nurse consultfirst?1.Ask the patient if he typically needs extra medica-tion in the evening.2.Ask the HCP to verify that the larger amount isthe correct dose.3.Ask the pharmacist to confirm the dosage on theoriginal prescription.4.Ask the charge nurse if this is a typical dosage fornighttime PCA.
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 27 preview imageCHAPTeR1Pain16Copyright © 2022, Elsevier Inc. All rights reserved.Answer Key for this chapter begins on p. 19Common Health ScenariosPART 242.Which instruction would the nurse give to the unli-censed assistive personnel (AP) related to the care of apatient who has received ketamine for analgesia?1.Keep the environment calm and quiet.2.Watch for and report respiratory depression.3.Offer frequent sips of noncaffeinated fluids.4.Keep the bed flat and frequently turn patient.43.The health care provider (HCP) prescribes 7 mg mor-phine IV as needed. The nursing student prepares themedication and shows the syringe (see figures below)to the nursing instructor. Which action would thenursing instructor takefirst?1.Tell the student to review the HCP’s prescriptionbefore administering medication.2.Waste the medication and tell the student that re-mediation is required for serious error.3.Ask the student to demonstrate the calculationsand steps required to prepare the dose.4.Accompany the student to the patient’s room andobserve as the medication is administered.10mL241368957Scenario:The nurse is caring for a patient who had abdominal surgeryyesterday. The patient is restless and anxious and reports that the pain isgetting worse (8 out of 10) despite morphine via patient-controlled an-algesia. Physical assessment findings include: T 100.3°F (37.9°C), P 110beats/min, R 24 breaths/min, and BP 110/70 mmHg. The abdomen isrigid and tender to the touch with hypoactive bowel sounds. The nursetries to make the patient comfortable, and he is willing to wait until thenext scheduled dose of pain medication. However, the nurse decides tonotify the patient’s health care provider (HCP) because the pain warrantsevaluation, possible diagnostic testing, and additional therapies.Which information would the nurse include in the assessment compo-nent of the SBAR (situation, background, assessment, recommendation)report to the HCP?Instructions:Underline or highlight theinformation the nurse would include inthe assessment component of the SBARreport.44.Expanded Hot Spot____________________________________________________________________________
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 28 preview imageCHAPTeR1Pain17Copyright © 2022, Elsevier Inc. All rights reserved.Answer Key for this chapter begins on p. 19Common Health ScenariosPART 245.Extended Multiple Response_____________________________________________________________________Question:Based on the American Society for Pain ManagementNursingrecommendationsfor“Asneeded”(PRN)rangeprescriptions for opioid analgesics, for which prescriptions, doesthe nurse need to seek clarification from the health care provider?Instructions:Place an X in the space provided orhighlight each patient situation where the nursewould seek clarification for the prescrip-tion.Selectall that apply.The nurse is reviewing the PRN (as-needed) pain prescriptions for the following patients:1.______Ms. A is a 35-year old female admitted for an acute episode of cholelithiasis. Prescribed: Morphine 1 to 15 mgIV every 2 hours PRN pain2.______Mr. B is a 75-year old male who had hip surgery yesterday. He has chronic obstructive pulmonary disease.Prescribed: Morphine 2 to 3 mg IV every 2 hours PRN pain3.______Mr. C is a 55-year old male with acute pancreatitis. He has a history of alcohol and substance abuse. Prescribed:Morphine 1 to 3 mg IV every 4 hours PRN pain4.______Mrs. D is an 83-year old female with an ankle fracture. She has dementia and is unable to maintain elevationof the ankle. Prescribed: Meperidine 25 to 50 mg PO PRN pain5.______Mr. E is a 46-year old male admitted for bacterial meningitis. He reports severe headaches. Prescribed:Codeine 15 mg PO 1-2 tablets every 4 to 6 hours PRN pain6.______Mr. F is a 25-year old male. He has extensive abrasions on the left side of the body sustained in a motorcycleaccident. No other obvious trauma detected in the emergency department. Prescribed: Oxycodone 9 mg POevery 12 hours; Hydrocodone with acetaminophen 5/325 PO 1 to 2 tablets every 4 to 6 hours PRN pain;acetaminophen 500 mg 2 tablets PO every 6 to 8 hours PRN pain7.______Ms. G is a 57-year old female who had a hysterectomy yesterday for uterine prolapse. She is opioid naive andhas no preexisting health conditions other than prolapse of the uterus. Prescribed: Fentanyl 50 to 100 mcg IVevery 2 hours PRN for severe pain8.______Mr. H is a 68-year old male; he has pain associated with postherpetic neuralgia. Prescribed: Morphine 2 to3 mg IV every 4 hours PRN painScenario:The nurse is caring for a 73-year old patient who was admittedfor dehydration and observation for compartment injury. The patient fellbetween the toilet and the wall. His right arm was pinned underneath hisbody, for several hours before he was discovered by a neighbor. Fracturesand other obvious injuries were ruled out in the emergency department.Patient received 400 mg ibuprofen for pain in the right arm.Which nursing actions would the nurse take for suspicion of compart-ment syndrome?Instructions:Foreachpotentialnurs-ing action listed below, check to specifywhether the action is anticipated, non-essential or contraindicated.Vital signs:Temperature 98.7F° (37°C)Pulse 120 beats/minRespirations 24 breaths/minBlood pressure 140/70 mmHgOxygen saturation 95% (on room air)Body Mass Index (BMI) 30Assessment findings:Patient is anxious and tearful. He reports stiff-ness and soreness in his right leg, but “My leg is okay compared to myarm. My arm really hurts (9/10 on pain scale). Stretching makes the painworse and there is burning and tingling in my fingers. When is that painmedication supposed to start working?”46.Matrix______________________________________________________________________________________
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 29 preview imageCHAPTeR1Pain18Copyright © 2022, Elsevier Inc. All rights reserved.Answer Key for this chapter begins on p. 19Common Health ScenariosPART 247.Drag and Drop________________________________________________________________________________Scenario:The oncoming day shift nurse has received theshift report from the night nurse. The day shift nurse hasdone a quick check on all of the patients and has deter-mined that all are stable and not in acute distress.In which order would the nurse care for these patients?Instructions:Patients are listed in the left-hand column.In the right- hand column write in the number to indicatethe order of priority for care; 1 being the first and 5 beingthe last.PatientsOrder of priority1.17-year-old adolescent who is alert and oriented. He was admitted 2 daysago for treatment of meningitis. He reports a continuous headache that ispartially relieved by medication.2.65-year-old man who underwent total knee replacement surgery 2 days ago.He is using the patient-controlled analgesia (PCA) pump frequently andoccasionally asks for a bolus dose.3.53-year-old woman who is demanding and frequently calls for assistance. Shewas admitted for investigation of functional abdominal pain and is scheduledfordiagnostic testing this morning.4.82-year-old woman with advanced Alzheimer disease who requires total carefor all activities of daily living. She will be transferred to a long-term carefacility in a few days after arrangements are finalized.5.26-year-old man who was admitted with chest pain secondary to a spontane-ous pneumothorax.Today, the chest tube will be removed and the PCA pumpwill be discontinued.Potential Nursing ActionsAnticipatedNonessentialContraindicatedAssess the location, quality, and intensity of painAssess for 5Ps (pain, pallor, pulselessness, paralysis, paresthesia)Elevate right arm above the level of the heartApply an ice pack wrapped in a towelAssess urine color and outputWrap the forearm with an elastic bandageObtain an order for an x-ray of the armNotify health care provider for unrelieved pain and paresthesia
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 30 preview imageCopyright © 2022, Elsevier Inc. All rights reserved.IntroductionPART 118.e1Answers1.Ans: 3The patient must be believed, and his or herexperience of pain must be acknowledged as valid. Thedata gathered via patient reports can then be appliedto the other options in developing the treatment plan.Focus:Prioritization;QSEN:PCC;Concept:Pain;Cognitive Level:Applying.2.Ans: 1, 3, 4The widespread use of opioids and theincrease in mortality and morbidity make it essentialfor nurses to recognize any personal negative bias andwork toward conveying acceptance and understand-ing. This increases the likelihood of patient engage-ment and success in treatment programs. Learningabout the signs and symptoms of an opioid overdoseand the proper use of naloxone is also a nursing re-sponsibility. Electronic prescription drug monitoringprograms show promise but are not currently availablenationwide and checking the database for all opioidprescriptions may be time-consuming and unneces-sary (short-term opioid prescriptions for acute painare less problematic). The nurse would question ahealth care providerif an opioid prescription did notseem safe; however, the CDC recommendations arenot legally binding and deviations are not report-able.Focus:Prioritization;QSEN:EBP, S;Concept:Pain;Cognitive Level:Analyzing.3.Ans: 4Assess the pain for changes in location,quality, and intensity, as well as changes in responseto medication. This assessment will guide the nextsteps.Focus:Prioritization;QSEN:EBP;Concept:Pain;Cognitive Level:Applying.TestTaking Tip:During clinical rotations, you may observe nurses giv-ing pain medication without performing an adequatepain assessment. This is an error in clinical perfor-mance. In postoperative patients, pain could signalcomplications, such as hemorrhage, infection, or de-creased perfusion related to tissue swelling. Alwaysassess pain first, then make a decision about givingmedication,usingnonpharmacologicmethods,orcontacting the HCP.4.Ans: 4The LPN/LVN is well trained to administeroxygen per nasal cannula. This patient is consideredunstable; therefore the RN should take responsibil-ity for administering drugs and monitoring the re-sponse to therapy, which includes the effects on therespiratory system. The RN should also take respon-sibility to communicate with the HCP for ongoingtreatment and therapy.Focus:Assignment;QSEN:TC;Concept:Clinical Judgment;Cognitive Level:Analyzing;IPEC:R/R.5.Ans: 4If the pain is constant, the best schedule isaround-the-clock to provide steady analgesia and paincontrol. The other options may require higher dosagesto achieve control.Focus:Prioritization;QSEN:EBP;Concept:Pain;Cognitive Level:Applying.6.Ans: 4At greatest risk are older adult patients,opioid-naïve patients, and those with underlying pul-monary disease. The adolescent has two of the threeriskfactors.Focus:Prioritization;QSEN:EBP;Concept:Pain;Cognitive Level:Applying.7.Ans: 4One of the common features of rheumatoidarthritis is joint pain and stiffness when first rising.This usually resolves over the course of the day. A non-pharmaceutical measure is to take a warm shower (orapply warm packs to joints if pain is limited to one ortwo joints). If pain worsens, then the nurse may electto contact other members of the health care team foradditional interventions.Focus:Delegation;QSEN:TC;Concept:Pain;Cognitive Level:Applying;IPEC:R/R.8.Ans:1Gabapentinisanantiepilepticdrug,butitisalsousedtotreatdiabeticneuropathy.Corticosteroids are for pain associated with inflam-mation. Hydromorphone is a stronger opioid, andit is not the first choice for chronic pain that can bemanaged with other drugs. Lorazepam is an anxiolyt-ic that may be prescribed as an adjuvant medication.Focus:Prioritization;QSEN:EBP;Concept:Pain;Cognitive Level:Applying.9.Ans: 1The goal is to control pain while minimizingside effects. For severe pain, the medication can be ti-trated upward until the pain is controlled. Downwardtitration occurs when the pain begins to subside.Focus:Prioritization;QSEN:EBP;Concept:Pain;Cognitive Level:Applying.10.Ans:1,2,3,4TherecommendationsoftheAmerican Pain Society, in collaboration with theAmerican Society of Anesthesiologists, for postopera-tive patients include: acetaminophen and/or NSAIDsif there are no contraindications; surgical site–specificperipheral regional anesthetic for procedures; neuraxi-al analgesia (also known as epidural analgesia) for ma-jor thoracic and abdominal procedures, if patient hasrisk for cardiac complications or prolonged ileus; andmultimodal therapy, which includes use of differenttypes of medications and other therapies. Oral opioidsare preferred in the postoperative period. Pain special-ists should be consulted if patients have inadequatelycontrolled postoperative pain.Focus:Prioritization;QSEN:EBP;Concept:Pain;Cognitive Level:Understanding. TestTaking Tip:Passing a test andworking as a competent nurse requires keeping up todate with current practice guidelines.11.Ans: 3Beliefs, attitudes, and familial influence arepart of the sociocultural dimension of pain. Location
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Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021) - Page 31 preview image18.e2Copyright © 2022, Elsevier Inc. All rights reserved.CHAPTeR1PainIntroductionPART 1and radiation of pain address the sensory dimension.Describing pain and its effects addresses the affectivedimension. Activity level and function address the be-havioral dimension. Asking about knowledge address-es the cognitive dimension.Focus:Prioritization;QSEN:PCC;Concept:Pain;Cognitive Level:Analyzing.12.Ans: 3Cancer pain generally worsens with diseaseprogression, and the use of opioids is more generous.Fibromyalgia is more likely to be treated with non-opioid and adjuvant medications. Trigeminal neu-ralgia is treated with antiseizure medications suchas carbamazepine. Phantom limb pain usually sub-sides after ambulation begins.Focus:Prioritization;QSEN:EBP;Concept:Pain;Cognitive Level:Applying.13.Ans: 1Multimodal therapies for postoperative pa-tients include opioids and nonopioid therapies, re-gional anesthetic techniques, and nonpharmacologictherapies. This approach is thought to be the most im-portant strategy for pain management for most post-operative patients. Standing orders are less optimalbecause there is no consideration of individual needsor characteristics. PCA is one important element, butnot all patients can manage PCA devices. Assessmenttoolsareanimportantpartofoverallmanage-ment, but basing opioid dose on a numerical scaledoes not consider individual patient circumstances.Focus:Prioritization;QSEN:EBP;Concept:Pain;Cognitive Level:Understanding.14.Ans: 4When supervising a new RN, good per-formance should be reinforced first and then areasof improvement can be addressed. Asking the nurseabout knowledge of pain management is also an op-tion; however, it would be a more indirect and time-consuming approach. Making a note and watchingdoes not help the nurse to correct the immediateproblem. In-service training might be considered ifthe problem persists.Focus:Supervision;QSEN:TC, QI;Concept:Leadership;Cognitive Level:Applying.15.Ans: 1, 3, 5, 6Patients with acute conditions thatrequire close monitoring for complications should beassigned to an experienced RN. Abdominal crampssecondary to food poisoning is an acute condition;however, cramping, vomiting, and diarrhea are usu-ally self-limiting. The patient with chronic back painwould be considered physically stable. Although allpatients will benefit from care provided by an experi-enced RN, the patient with abdominal cramps and thepatient with back pain could be assigned to a new RN,an LPN/LVN, or a float nurse.Focus:Assignment;QSEN:TC;Concept:Clinical Judgment;CognitiveLevel:Analyzing;IPEC:T/T.Test Taking Tip:To determine acuity of patients, use nursing con-cepts, such as gas exchange and perfusion. Patients 1,3, 5, and 6 could have potential problems related toperfusion. The patient with the chest tube could alsohave a potential problem related to gas exchange.16.Ans: 2Inadequate pain management for postsurgi-cal patients can affect quality of life, function, recovery,and postsurgical complication; thus all the manifes-tations are examples of negative results. Nevertheless,venous thromboembolism is the most serious becauseit can lead to pulmonary embolism, which is an imme-diate life-threatening concern. The nurse also needstoimplementinterventionstoresolveunsatisfiedneeds, fear of pain, and hopelessness related to painand function.Focus:Prioritization;QSEN:PCC, S;Concept:Pain;Cognitive Level:Analyzing.TestTaking Tip:Physiologic needs are the first concern.In this case, venous thromboembolism is the mostserious physiologic outcome secondary to inadequatepain management.17.Ans: 1The nurse would consider questioning all ofthe medication prescriptions, but the opioid-naïveadult has the greatest immediate risk because use ofa basal dose has been associated with an increased in-cidence of respiratory depression in opioid-naïve pa-tients. Older adults are frequently prescribed NSAIDs;however, they are used with caution, and the patient’shistory should be reviewed for potential problems,such as a history of gastrointestinal bleeding, cardiacdisease, or renal dysfunction. Many medications suchas anticoagulants, oral hypoglycemics, diuretics, andantihypertensives can also cause adverse drug–druginteractions with NSAIDs. IM injections cause pain,absorption is unreliable, and there are no advantagesover other routes of administration. If a patient is ableto tolerate oral foods and fluids, oral medications arepreferred because the efficacy of the oral route is equalto the IV route.Focus:Prioritization;QSEN:EBP,S;Concept:Pain;Cognitive Level:Analyzing.TestTaking Tip:It is worthwhile to study the purposes,pharmacologic actions, and side effects of commonlyused medications. Morphine is considered the proto-type of the opioid medications. For opioid-naïve pa-tients, the priority concern is respiratory depression.For patients who need opioids for long-term painmanagement, the primary side effect is constipation.18.Ans: 3The patient with an acute myocardial infarc-tion has the greatest need for IV access and is likelyto receive morphine, which will relieve pain and in-crease venous capacitance. The other patients may alsoneed IV access for delivery of pain medication, otherdrugs, or IV fluids, but the need is less urgent.Focus:Prioritization;QSEN:EBP;Concept:ClinicalJudgment;Cognitive Level:Analyzing.19.Ans: 2The AP has correctly reported findings, butthe nurse is ultimately responsible to assess first andthen determine the correct action. Based on assess-ment findings, the other options may also be appro-priate.Focus:Prioritization;QSEN:EBP;Concept:Clinical Judgment;Cognitive Level:Applying.
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