A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? (Choose all that apply).
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Solution
Administer phenytoin (Dilantin) 200 mg PO daily.
Option B: Administration of medications is included in LPN education and scope of practice. Collection of data about the seizure activity may be accomplished by an LPN/LVN who observes initial seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient started to seize.
Options A, C, and D: Documentation of the seizure, patient teaching, and planning of care are complex activities that require RN level education and scope of practice. Focus: Delegation
You are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient with meningococcal meningitis. Which action by the student requires that you intervene immediately?
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Solution
The student enters the room without putting on a mask and gown.
Option A: Meningococcal meningitis is spread through contact with respiratory secretions so use of a mask and gown is required to prevent spread of the infection to staff members or other patients. The other actions may not be appropriate but they do not require intervention as rapidly.
Option B: The presence of a family member at the bedside may decrease patient confusion and agitation.
Option C: Patients with hyperthermia frequently complain of feeling chilled, but warming the patient is not an appropriate intervention.
Option D: Checking the pupil response to light is appropriate, but it is not needed every 30 minutes and is uncomfortable for a patient with photophobia. Focus: Prioritization
You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which collaborative intervention must be accomplished first?
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Solution
Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.
Option B: Untreated bacterial meningitis has a mortality rate approaching 100%, so rapid antibiotic treatment is essential.
Options A, C, and D: The other interventions will help reduce CNS stimulation and irritation and should be implemented as soon as possible. Focus: Prioritization
The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant who will feed the patient?
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Solution
Position the patient sitting up in bed before you feed her.
Option A: Positioning the patient in a sitting position decreases the risk of aspiration.
Option B: The nursing assistant is not trained to assess gag or swallowing reflexes.
Option C: The patient should not be rushed during feeding.
Option D: A patient who needs to be suctioned between bites of food is not handling secretions and is at risk for aspiration. This patient should be assessed further before feeding. Focus: Delegation/supervision
Which action (s) should you delegate to the experienced nursing assistant when caring for a patient with a thrombotic stroke with residual left-sided weakness? (Choose all that apply).
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Solution
Answer: A, B, and C
Options A, B, and C: The experienced nursing assistant would know how to reposition the patient and how to reapply compression boots, and would remind the patient to perform activities he has been taught to perform.
Option D: Assessing for redness and swelling (signs of deep venous thrombosis {DVT}) requires additional education and still appropriate to the professional nurse. Focus: Delegation/supervision
You are supervising a senior nursing student who is caring for a patient with a right hemisphere stroke. Which action by the student nurse requires that you intervene?
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Solution
The student instructs the patient to sit up straight, resulting in the patient’s puzzled expression.
Option A: Patients with right cerebral hemisphere stroke often present with neglect syndrome. They lean to the left and when asked, respond that they believe they are sitting up straight. They often neglect the left side of their bodies and ignore food on the left side of their food trays. The nurse would need to remind the student of this phenomenon and discuss the appropriate interventions. Focus: Delegation/supervision
You are providing care for a patient with an acute hemorrhage stroke. The patient’s husband has been reading a lot about strokes and asks why his wife did not receive alteplase. What is your best response?
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Solution
“Alteplase dissolves clots and may cause more bleeding into your wife’s brain.”
Option C: Alteplase is a clot buster. With patient who has experienced hemorrhagic stroke, there is already bleeding into the brain. A drug like alteplase can worsen the bleeding.
Options A, B, and D: The other statements are also accurate about use of alteplase, but they are not pertinent to this patient’s diagnosis. Focus: Prioritization
The nursing assistant reports to you, the RN, that the patient with myasthenia gravis (MG) has an elevated temperature (102.20 F), heart rate of 120/minute, rise in blood pressure (158/94), and was incontinent off urine and stool. What is your best first action at this time?
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Solution
Notify the physician immediately.
Option B: The changes that the nursing assistant is reporting are characteristics of myasthenia crisis, which often follows some type of infection. The patient is at risk for inadequate respiratory function. In addition to notifying the physician, the nurse should carefully monitor the patient’s respiratory status. The patient may need intubation and mechanical ventilation.
Option A: The nurse would notify the physician before giving the suppository because there may be orders for cultures before giving acetaminophen.
Option C: This patient’s vital signs need to be re-checked sooner than 1 hour.
Option D: Rescheduling the physical therapy can be delegated to the unit clerk and is not urgent. Focus: Prioritization
The LPN/LVN, under your supervision, is providing nursing care for a patient with GBS. What observation would you instruct the LPN/LVN to report immediately?
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Solution
Shallow respirations and decreased breath sounds
Option D: The priority interventions for the patient with GBS are aimed at maintaining adequate respiratory function. These patients are risk for respiratory failure, which is urgent.
Options A, B, and C: The other findings are important and should be reported to the nurse, but they are not life-threatening. Focus: Prioritization, delegation/supervision
The patient with multiple sclerosis tells the nursing assistant that after physical therapy she is too tired to take a bath. What is your priority nursing diagnosis at this time?
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Solution
Self-care Deficit related to fatigue and neuromuscular weakness
Option D: At this time, based on the patient’s statement, the priority is Self-Care Deficit related to fatigue after physical therapy.
Options A, B, and C: The other three nursing diagnoses are appropriate to a patient with MS, but they are not related to the patient’s statement. Focus: Prioritization