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Prioritization and Delegation - ML8 (1)
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Prioritization and Delegation - ML8 (1)
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Prioritization and Delegation - ML8The nurse is caring for a client with functional neurologic symptom disorder who has experienced
pseudoseizures. What intervention is appropriate for the nurse to perform?
Encourage the client to discuss feelings about the pseudoseizures.
Ignore the client's pseudoseizures to prevent reinforcement.
Administer a placebo as prescribed by the health care provider.
Explain to the client that the pseudoseizures are not real seizures. - CORRECT
ANSWER-Encourage the client to discuss feelings about the pseudoseizures.
Pseudoseizures or psychogenic nonepileptic seizures are considered a psychological symptom
and are not related to electrical disturbance in the central nervous system as epileptic seizures
are. However, they are a serious disorder and should not be minimized to the client by the nurse.
Cognitive behavioral therapy is a primary intervention and requires open dialogue between the
client and nurse so the client should be encouraged to verbalize feelings. Placebo administration
is unethical, and the nurse should not participate in this intervention. While the nurse should
remain calm and not draw excessive attention to the client during a pseudoseizure, the nurse
should not ignore the client outright.
The nurse is providing community education to a group of clients about the prevention of type 2
diabetes mellitus. Which client would be at highest risk for the development of diabetes mellitus?
A middle-age man with a basal metabolic rate within normal limits
A middle-age woman who delivers mail
An elderly woman who is sedentary
A young adult who plays basketball regularly - CORRECT ANSWER-An elderly woman who is
sedentary
The risk for developing type 2 diabetes mellitus is increased in clients over 65 years of age.
Maintaining a normal weight and basal metabolic rate, along with exercise decrease the risk. The
risk is increased with a lack of exercise.
The nurse is caring for a client struggling with alcohol dependence. It is most important for the
nurse to:
confront feelings and examples of perfectionism.
avoid blaming or preaching to the client.
speak briefly and directly.
determine if nonverbal communication will be more effective. - CORRECT ANSWER-avoid
blaming or preaching to the client.
Blaming or preaching to the client causes negativity and prevents the client from hearing what the
nurse has to say. Speaking briefly to the client may not allow time for adequate communication.
Perfectionism doesn't tend to be an issue. Determining if nonverbal communication will be more
effective is better suited to a client with cognitive impairment.
The nurse is preparing to administer digoxin to an infant. What is the most important intervention
by the nurse?
Withhold the dose if the apical pulse rate is less than 90/bpm
,Give the digoxin with antacids when possible
Mix the digoxin with the infant's food
Double the subsequent dose if a dose is missed - CORRECT ANSWER-Withhold the dose if the
apical pulse rate is less than 90/bpm
Digoxin is used to decrease the heart rate; however, the apical pulse must be carefully monitored
to detect a severe reduction. Administering digoxin to an infant with a heart rate of less than
90/bpm could further reduce the rate and compromise cardiac output. Mixing digoxin with food
may interfere with accurate dosing. Double dosing should never be done. Antacids may decrease
drug absorption.
A nurse finds a client crying after being told by the health care provider that the client is to start
hemodialysis to treat acute renal failure. What is the nurse's most important intervention?
Discuss the other abilities the client has.
Refer the client to the hemodialysis team.
Sit quietly with the client.
Remind the client this is a temporary situation. - CORRECT ANSWER-Sit quietly with the client.
Sitting with the client shows compassion and concern and may help the nurse establish
therapeutic communication. Making a referral doesn't allow the client to explore feelings with the
nurse. The nurse can't guarantee the acute renal failure is temporary. Discussing the client's other
abilities diverts the emphasis from the client's primary issue.
What is the most important nursing intervention when caring for a child with a newly applied wet
hip spica cast?
Reposition the child every 1 to 2 hours.
Use the fingertips when handling the cast.
Cover the cast in plastic to keep it clean.
Use the abductor bar to help move the child. - CORRECT ANSWER-Reposition the child every 1
to 2 hours.
The child in a wet hip spica cast should be turned every 1 to 2 hours to help dry all sides of the
cast and prevent skin breakdown. The abductor bar shouldn't be used for turning the child, even
after the cast is dry. A wet cast shouldn't be covered with plastic because this will impede drying,
reduce air circulation, and allow heat to build up in the cast. A wet cast should be handled using
the palms, because fingertips may cause indentations and pressure points.
A child has ingested a bottle of over-the-counter medication and is brought into the emergency
department by the parents. The nurse expedites rapid first aid for poisoning by immediately
accessing what resource?
contacting the Poison Control Center by phone
reviewing the treatment for overdose on the medication bottle
reviewing the emergency department poison control guidelines
consulting the current Compendium of Pharmaceuticals and Specialties (CPS) - CORRECT
ANSWER-contacting the Poison Control Center by phone
,Despite having directions on the bottle or in the CPS about what to do in the event of overdose of
medications, best practice dictates the nurse contact the Poison Control Center for directions.
Often, medication labels are outdated and should not be followed. Written hospital guidelines may
also be out of date. Although making the call takes time, it guarantees the best treatment for the
poisoning.
A client with alcohol withdrawal syndrome is pulling at the central venous catheter, saying, "I'm
swatting the spiders crawling all over me." What is the nurse's priority action?
Encourage the client to rest.
Tell the client there are no spiders.
Explain that the client is pulling the I.V. tubing.
Assign a nursing assistant to stay with the client. - CORRECT ANSWER-Assign a nursing
assistant to stay with the client.
During periods of alcohol withdrawal syndrome, the client needs to be protected from harm. If the
client dislodges the central venous catheter, an air embolus may develop, which can be life
threatening. Although reality should be presented to the client, explaining that there are no spiders
and that the I.V. tubing is being pulled may not make the client stop; therefore, the client's safety is
still at risk. The client may need to be restrained if continued observation during this time isn't
available. The client should also be encouraged to rest; however, this intervention doesn't take
priority over safety.
The nurse is caring for a client in the post anesthesia care unit (PACU) following an
adrenalectomy. What is the nurse's priority action?
Administering dextrose in water
Administering opioids
Assessing blood pressure
Assessing serum potassium - CORRECT ANSWER-Assessing blood pressure
Removing a major source of adrenal hormones may cause a state of temporary adrenal
insufficiency. After an adrenalectomy, the patient is usually sent to a critical care unit. Immediately
after surgery, the patient should be assessed every 15 minutes for shock due to possible
insufficient glucocorticoid replacement. Assessment is a priority over interventions. Assess the
blood pressure, then electrolytes, and finally assess the client for fluid replacement and pain
management needs.
Parents bring a preschool-age client to the emergency department with suspected ingestion of an
unknown toxic substance. What intervention should the nurse perform first?
Establish intravenous access, and provide supplemental oxygen.
Interview the parents about the initial onset of symptoms.
Ask the parents what they think the child ingested.
Assess the child's vital signs and neurological status. - CORRECT ANSWER-Assess the child's
vital signs and neurological status.
The nurse must assess the child to determine if life-saving intervention such as cardiopulmonary
resuscitation is needed. This assessment will direct all the subsequent actions, such as the
application of oxygen and intravenous fluids. The parents have indicated the source of suspected
, poisoning is unknown, so although interviewing them to try to determine the possible source and
the initial symptoms should be done, the nurse must first assess and stabilize the child.
The nurse is assigned to care for four clients. Which client should the nurse assess first?
A client admitted one day ago with thrombophlebitis who is receiving IV heparin
A client admitted one hour ago with new-onset atrial fibrillation who is receiving IV diltiazem
A client with end-stage, right-sided heart failure, with blood pressure of 78/50 mmHg, who is on
hospice care
A client admitted two days ago with heart failure, blood pressure of 126/76 mmHg, and a
respiratory rate of 22 breaths/min - CORRECT ANSWER-A client admitted one hour ago with
new-onset atrial fibrillation who is receiving IV diltiazem
The client with atrial fibrillation has the greatest potential to become unstable, and is on IV
medication that requires close monitoring. After assessing this client, the nurse should assess the
client with thrombophlebitis who is receiving a heparin infusion, and then the client admitted two
days ago with heart failure. The client with end-stage right-sided heart failure, who is identified as
a hospice client is of lowest priority.
The nurse is preparing to discharge a school-age child with asthma. Which intervention is most
important for the nurse to perform prior to discharge?
Counsel the family in making arrangements to remove the family pet.
Discuss limitations on the child's participation in sports activities.
Obtain additional equipment and medication that can be provided at the school.
Arrange for a thorough, deep cleaning of the home. - CORRECT ANSWER-Obtain additional
equipment and medication that can be provided at the school.
The child needs to have equipment and medication available at school to treat and prevent
asthma attacks. This is the priority intervention at this time. Discussions should be held with the
child and family to motivate the child to be involved in as many normal activities as possible; the
emphasis is on the options rather than the limitations. The nurse should teach the parents that the
house should be kept as clean as possible on an ongoing basis to prevent exacerbations due to
dust and pet dander, but it is not the nurse's responsibility to arrange for this cleaning. If the child
is allergic to the family pet, the nurse should provide counseling on ways to minimize the risks, but
this does not necessarily mean removal of the pet.
A 17-year-old primigravida with severe hypertension of pregnancy has been receiving magnesium
sulfate I.V. for 3 hr. The latest assessment reveals deep tendon reflexes (DTR) of +1, flushing,
blood pressure of 150/100 mm Hg, a pulse of 92 beats/min, a respiratory rate of 10 breaths/min,
and urine output of 20 ml/hr. Which action would be most appropriate?
Continue monitoring per standards of care.
Increase the infusion rate by 5 gtt/min.
Decrease the infusion rate by 5 gtt/min.
Stop the magnesium sulfate infusion. - CORRECT ANSWER-Stop the magnesium sulfate
infusion.
Magnesium sulfate should be withheld if the client's respiratory rate or urine output falls, or if
reflexes are diminished or absent, all of which are true for this client. The client also shows other
signs of impending toxicity, such as flushing and feeling warm. Inaction will not resolve the client's
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