Delegation/Prioritization

Question 1

RN may delegate what tasks to UAP?

Answer 1

• basic care activities
• bathing
• grooming
• ambulation
• feeding (unless extreme aspiration risk)
• mouth care
• toileting
• VS
• I/O (but not IV fluid intake)
• weight
• dressing
• transfers
• post mortem care

Question 2

Before the RN delegates any nursing intervention, additional factors should be considered:

Answer 2

1. Stability of patient condition
2. Complexity of activity to be delegated
3. Potential for harm
4. Predictability of the outcome
5. Overall context of any other patient needs

Question 3

RN may NOT delegate what tasks to UAP?

Answer 3

• assessment
• discharge planning
• health education
• care planning
• triage
• interpretation of patient data
• care of invasive lines
• administering parenteral medications

Question 4

5 Rights of Delegation

Answer 4

1. Right Task
2. Right Circumstance
3. Right Person
4. Right Directions and Communication
5. Right Supervision and Evaluation

Question 5

TAPE Acronym

Answer 5

• things RN cannot delegate
• T: Teaching
• A: Assessment
• P: Planning
• E: Evaluation

Question 6

ABCS: Airway Assessment and Interventions

Answer 6

• PATENCY
• Assessment: foreign body, chest movement, talking, cyanosis, obstruction, fluids, edema , LOC
• Interventions: maneuvers to remove foreign body (suction), oxygenation, intubate/trach

Question 7

ABCS: Breathing Assessment and Interventions

Answer 7

• OXYGENATION
• Assessment: RR, breathing workload, bilateral breath sounds, good airway entry, SPO2
• Interventions: oxygenation device, noninvasive ventilation, ambu. bag/BMV

Question 8

ABCS: Circulation Assessment and Interventions

Answer 8

• PERFUSION
• Assessment: pulses, cap refill, skin temp, skin color, BP (hypotension), HR/cardiac rhythm, LOC
  Interventions: address causes, fluids, pressers (last resort)

Question 9

ABCS + D & E: Disability Assessment

Answer 9

• neurological status/GCS
• PERRLA
• blood glucose (hypo/hyperglycemia)
• check for drug causes
• urine output
• pain

Question 10

ABCS + D & E: Exposure Assessment

Answer 10

• check temperature
• expose patient
• head to toe skin assessment
• consider DVT and causes

Question 11

Maslow’s Hierarchy of Needs Order of Prioritization and Examples

Answer 11

1. Physiologic Needs (food, water, warmth, shelter, TPN, fluids)
2. Safety and Security (LOC)
3. Belongingness and Affection (relationships, family support, therapeutic communication)
4. Esteem and Self-Respect (accomplishment, respect)
5. Self-Actualization (full potential, coping, creativeness)

Question 12

ADPIE

Answer 12

• A: Assess (know patient baseline)
• D: Diagnosis (nursing diagnosis)
• P: Planning (choose and prioritize interventions r/t SMART goals)
• I: Implement
• E: Evaluate

Question 13

SMART Goals

Answer 13

• S: Specific (well defined, who, what, where, why)
• M: Measurable (criteria to quantify progress)
• A: Achievable (attainable goals)
• R: Relevant (overall goal objective)
• T: Time-bound (deadline, gives sense of urgency)

Question 14

Spectrum of Stability

Answer 14

1. life threatening; life altering
2. unexpected outcome for disease process
3. abnormal data (critical lab value, etc.)
4. expected outcome for disease process; not life threatening
5. normal data (consistent lab values, VS, ready for discharge, etc.)

Question 15

3 Types of Prevention

Answer 15

1. Primary: promote health
2. Secondary: screening
3. Tertiary: after a diagnosis has been made; maximize patient’s functioning