How to answer PRIORITIZATION AND DELEGATION

Johnasse Sebastian C. Naval, RN, USRN, MANc

PRIORITIZATION
◦ STEP 1. Eliminate the stable patient. ( normal value, stable V/S, pain
below 5, discharge and waiting for 24 diagnostic procedures).
◦ STEP 2. Eliminate the symptoms that expected from the DIAGNOSIS.
◦ EX. Client with cellulitis with 100.2 and pain 6/10 EXPECTED
◦ EX Client with cellulitis with confusion. UNEXPECTED-
COMPLICATION-OUT OF SYSTEM
◦ STEP 3. Follow the MASLOW hierarchy of need. ABC, eliminate if the
INTERVENTION can be delayed. ABC priority keyword DYPSNEA, SP02 less
than 94% except COPD, restlessness, CHEST PAIN, HYPO/TACHY/TACHY,
pale/cold/clammy, unresponsive, foreign body aspiration, post op
complication such as bleeding, peritonitis ( board like rigid abdomen)
◦ STEP 4. REVIEW, if everything is expected PSYCHOSOCIAL problem is the
answer.
PRACTICE QUESTION #1: You are the team
leader in Medical Surgical Unit. Which patient
will you assess
First?
1. Post 2 days left hip replacement with chest
pain while ambulating.
2. 24 y/o female patient newly diagnosed with
chronic pancreatitis complaining of 8/10
pain.
3. 45 y/o with Acute Pericarditis complaining
chest pain 6/10 while coughing.
4. 18 y/o 1 week post ORIF with swelling leg,
foul drainage.
PRACTICE QUESTION #2: You are the team leader in M/S
Unit, morning shift. Which patient will you assess First?
1. A 30 y/o patient with Multiple sclerosis who had bladder
incontinence this morning.
2. A 65 y/o patient with dementia who is wandering at the
hallway.
3. A 72 y/o patient 3 days post CVA who needs swallowing
assessment.
4. A 23 y/o patient post laparoscopic cholecystectomy
complaining RUQ pain.
PRACTICE QUESTION #3: The office nurse
receives 4 telephone messages. Which
client should the nurse call back first?
1. Client who fell from stairs yesterday who
has low back pain.
2. 18 y/o male athlete who has sharp pain
radiating from buttock to knee after
training.
3. Client with vascular disease who has
sudden abdominal pain radiating to the
low back.
4. Client who PAD complaining of leg pain
while walking.
PRACTICE QUESTION #4. Which client warrants
immediate intervention from the nurse on the
medical unit?
1. 23 y/o IV drug user with swelling left arm and foul
smelling drainage from self-injection site.
2. 19 y/o college student who has fever, headache,
nausea and vomiting, photophobia and +
kernig’s sign.
3. 35 y/o DM II patient with leg infection, serum
glucose of 485 mg/dl.
4. 65 y/o patient 2 days post angioplasty with
occasional PVC.
LET’S PRACTICE MORE!!!
5. Nurse Wayne is receiving endorsement from
night shift nurse. Which client should nurse
Kramer visit first?
1. Client with DKA who has rapid, deep
respiration of 35rpm.
2. Client 6 hours postoperative billroth 2 who is
nauseated and retching.
3. Client who is for DNR and the family member
is questioning the order.
4. Client with Chronic lymphocytic leukemia with
hgb level of 8 mg/dl and HR of 112 after
ambulation,
6. George is caring for the following clients on the
Neurological Intensive Care unit.
Which client should Courtney assess first?
1. The client with T8 SCI who is complaining of
headache.
2. The client with Guillain-Barré syndrome who is
complaining ascending paralysis.
3. The client with traumatic brain injury who has a
Glasgow Coma Scale score of 11 from 13 one hour
ago.
4. The client diagnosed with a cerebrovascular
accident (CVA) who has expressive
aphasia.
7. The nurse has just received a change-of-shift report about these clients on
the coronary step-down unit. Which one will the nurse assess first?
1. A 26-year-old client with heart failure caused by congenital mitral stenosis
who is scheduled for balloon valvuloplasty later today
2. A 45-year-old client with constrictive cardiomyopathy who developed
acute dyspnea and agitation about 1 hour before the shift change
3. A 56-year-old client who underwent coronary angioplasty and stent
placement yesterday and has reported occasional chest pain since the
procedure
4. A 77-year-old client who was transferred from the intensive care unit 2
days ago after coronary artery bypass grafting and has a temperature of
100.6°F (38.1°C)
8. The nurse in an outpatient clinic is returning telephone calls. Rank the calls in
the
order they should be returned, with the highest priority call first.
1. The call from a daughter who states her mother started on antithyroid and
now the mother is not waking up.
2. The call from a client who had post unilateral adrenalectomy complaining
of facial swelling.
3. The client with hypothyroidism who is reporting feeling hot, having hand
tremors,
and having diarrhea.
4. The call from the newly diagnosed HPN taking ACE complaining of
intractable dry cough.
5. The call from the client who had a magnetic resonance imaging (MRI) scan
2 days
ago and has not received the results
DELEGATION
• ABC patient unless it is expected. Ex. COPD less than 94-95% Spo2 is expected but PNEUMONIA with
91% Spo2 is unexpected. MEDICALLY UNSTABLE, WITH UNEXPECTED OUTCOME
• Complication is out of the system. Ex. IBD (Gastro) with muscle weakness (muscle) is out of the system
but IBD with 20 watery stool is in the same system.
• Unexpected signs and symptoms. Ex. Chest pain in patient post ORIF.
• Something to ATE, initial ASSESS, COMPLLICATED/ NEW TEACHING and EVALUATE. CLINICAL
JUDGEMENT
• History taking, developing, planning, seeking, referral, transferring , diet plan, and suggesting.
• Patient who is newly admitted, just returned, newly diagnosed, new complaint, showing signs and
anxious.
• Initial and discharge education.
• Initiating blood transfusion.
• Receiving critical value from lab, reporting to HCP.

EXPERIENCE RN
• Patient with cytotoxic medication, newly implanted device.

• Patient who is manipulative and complaining.

• Acute patient with unstable signs and symptoms.

• Patient with multiple injuries, trauma and shock.

• Patient with altered GCS, VITAL SIGNS, LAB VALUES

• Patient with thrombocytopenia and neutropenic precautions with

complications.
• Dressing for STAGE 4 ulcer, injury, burn.
PRACTICE QUESTION 9.

The experience RN, LPN and UAP is receiving post thyroidectomy from
PACU. Which task is appropriate to delegate to the experience RN?
Sata
1. Receiving report from the PACU nurse
2. Monitoring vital signs
3. Reposition the patient every 2 hours.
4. Evaluating the response from pain medication
5. Monitoring pain and administering analgesic
6. Titrate oxygen administration
PRACTICE QUESTION 10

Which clients are appropriate to be assigned to an

experienced RN? Select all that apply.
1. Client who was in fraternity party complaining of vaginal
pain.
2. Client with chronic back pain related to a workplace
injury
3. Client who has a chest tube in place 3 days ago
4. Client post 2 days appendectomy with board like rigid
abdomen.
5. Client with a severe headache of unknown origin
• Stable with expected signs and symptoms.
• Chronic with no complication.
• All kinds of IV medication, IV complication ex. Infiltration.
• Routine procedure and assessment.
• Check, observe, monitor.
• Better to give a patient who is awaiting discharge or scheduled for procedure than a
patient who is for further assessment like newly diagnose, newly admitted patient.
• They can demonstrate, show, remind, reinforce and do basic teaching.
• They can receive a just returned patient if the other choices are unstable in multiple
choice.
• Just returned is accepted if the post op procedure is familiar and low risk.
• Receiving critical value from lab, reporting to HCP.

NEW RN “ Do not give new patient”

PRACTICE QUESTION # 11. The charge nurse is making assignments for clients on a
cardiac unit. Which client
should the charge nurse assign to a new graduate nurse?
1. The 44-year-old client diagnosed with a myocardial infarction 3 days ago and
with occasional pvc.
2. The 65-year-old newly admitted with stable angina.
3. The 75-year-old client scheduled for a cardiac catheterization who has frequent
pvc.
4. The 50-year-old client complaining of chest pain.
PRACTICE QUESTION # 12
Which clients are not appropriately to assigned to a newly graduated RN who
has recently completed orientation? Select all that apply.
1. Anxious client with chronic pain who frequently uses the call button
2. Client on the fourth postoperative day who is refusing to receive blood transfusion
3. Client with pneumonia who reports headache and pleuritic chest pain
4. Client with chronic kidney disease who is to be discharged with a new surgically implanted
fistula
5. Client who is reporting pain at the site of a peripheral IV line
6. Client with a kidney stone who needs frequent as needed (PRN) pain
medication
 LPN
• Stable with expected signs and symptoms.
• Chronic with no complication.
• All kinds of medication except IV, narcotics and chemo drugs.
• Routine procedure and follow –up assessment such as auscultation, dressing, inserting
catheter.
• Check, observe, monitor, assist, collect for stable patient.
• They can demonstrate, show, remind and reinforce.
• They can do the job of UAP if the question is SCOPE OF PRACTICE.
• Can give premeds- oral
• Can transcribe doctor’s order.
• Can give IV through piggyback.
• Can hang to follow IV with supervision.
• Can do ostomy/ sterile routine procedure
PRACTICE QUESTION13. An experienced LPN/LVN, under the
supervision of the team leader RN, is
assigned to provide nursing care for a patient with a respiratory
problem.
Which actions are appropriate to the scope of practice of an
experienced
LPN/LVN? Select all that apply.
1. Auscultating breath sounds
2. Administering medications via metered-dose inhaler (MDI)
3. Completing in-depth admission assessment
4. Checking oxygen saturation using pulse oximetry
5. Developing the nursing care plan
6. Evaluating the patient's technique for using MDIs
PRACTICE QUESTION 14

Which clients are not appropriately to assigned to an LPN/LVN who will

function under the supervision of an RN or team leader? Select all that
apply.
1. Client who needs preoperative teaching about the patient-controlled
analgesia pump
2. Client with a leg cast who needs neuro-circ checks and as needed (PRN)
hydrocodone
3. Client who underwent a toe amputation and has diabetic neuropathic pain
4. Client with terminal cancer and severe pain who is refusing medication
5. Client who reports abdominal pain after being kicked, punched, and beaten
6. Client with arthritis who needs scheduled pain medications and heat
applications
• Stable, expected signs and symptoms.
• Chronic with no complaints.
• Common IV meds. such as antibiotic, insulin and pain reliever.
• Routine procedure like dressing changes.
• Normal routine from the same unit.
• Ex. PACU/SICU nurse can handle just returned patient to other unit.
• Ex. ER nurse can do pain assessment to other unit.
• Ex. Burn unit nurse can do dressing changes.
• Do not give the patient who is for discharge OR scheduled for procedure

FLOAT NURSE /
TRAVEL NURSE
PRACTICE QUESTION #15. The charge nurse is making the daily assignments
on the medical-surgical unit. Which patient is best assigned to a float RN
who has come from the postanesthesia care unit (PACU)?
1. A 30-year-old patient with thalassemia major who has an order for
subcutaneous infusion of deferoxamine
2. A 43-year-old patient with multiple myeloma who requires discharge
teaching
3. A 52-year-old patient with chronic gastrointestinal bleeding who has
returned to the unit after a colonoscopy
4.A 65-year-old patient with pernicious anemia who has just been admitted
to the unit
•
•
Stable
No complaint, no difficulties
UAP
• Monitoring stable V/S, document quantity data.
• Assisting, feeding post 24-48 hours post stroke without difficulties.
• Applying skin barrier.
• Bed bath, oral hygiene, setting up meal tray.
• ADL, gathering basic supplies.
• Reminding, reinforce, reapply.
• Positioning stable patient.
• Giving oral glucose tablet.- school facility
• Reporting changes and complaints of patient to RN.
• Maintaining hygiene and changing of linens.
• Blood glucose monitoring to stable patient.
• Can check the responsiveness of patient but not assess, call for help but can’t announce a code.
• Can bring crash cart but can’t check the content.
• Bring blood sample to lab and take and return blood products,
• Can collect specimen but not sterile.
• Measure wound drainage
• Assist the nurse to ambulate the patient- initial
• Take the family members to the waiting room after patient goes to procedure
PRACTICE QUESTION#16. All of the following nursing care activities are
included in the care plan for a 78-year-old man with Parkinson disease who
has been referred to the home health agency. Which activities will the nurse
should not delegate to the unlicensed assistive personnel (UAP)? Select all
that apply.
1.Evaluating for orthostatic changes in pulse and blood pressure
2. Assessing for improvement in tremor after levodopa is given
3. Reminding the client to allow adequate time for meals
4. Monitoring for signs of toxic reactions to anti-Parkinson medications
5. Assisting the client with prescribed strengthening exercises
6. Adapting the client's preferred activities to his level of function
7. Monitor and report the patient output including the color.
LET’S PRACTICE MORE
PRACTICE QUESTION 17. The registered nurse is caring for multiple clients on a M/S unit.
Which task is appropriate to delegate for the UAP. SATA
1. Feed the 3 days post CVA via nasogastric tube.
2. Reinforce a wet to dry dressing to a 3rd degree pressure injury.
3. Assist a client 1 day postoperative knee replacement to the bathroom.
4. Offer juice to a client if the blood glucose level is less than 70 mg/dl.
5. Feed patient with dementia with blood glucose level of 70 mg/dl.
6. Assisting post chest tube patient to the bathroom for the first time after surgery.
PRACTICE QUESTION 18. Which tasks are not appropriate to assign to an
LPN/LVN who is functioning under the supervision of an RN? Select all
that apply.
1. Administering sulfacetamide sodium 10% to a child with conjunctivitis
2. Reviewing hand-washing and hygiene practices with clients who
have eye infections
3. Showing clients how to gently cleanse eyelid margins to remove
crusting
4. Assessing nutritional factors for a client with age-related macular
degeneration
5. Reviewing the health history of a client to identify risk for ocular
manifestations
6. Performing a routine check of a client's visual acuity using the Snellen
eye chart
PRACTICE QUESTION 19. The RN on M/S unit is working with a LPN and UAP. Which
tasks are most appropriate to assign to LPN? Select all that apply.
1. Taking data about the patient religious preference.
2. Performing wound care and sterile dressing change for a client with a stasis
ulcer.
3. Inserting nasogastric tube to a patient with acute pancreatitis.
4. Performing circulatory check for patient who has cast 1 week ago.
5. Assisting with bathing, feeding and dressing a client with multiple sclerosis.
PRACTICE QUESTION 20. The 19-year-old client is in the rehabilitation unit following a traumatic
brain injury.
Which intervention should the nurse delegate to the unlicensed assistive personnel
(UAP)? Select all that apply.
1. Make safety rounds hourly.
2. Refer the client to a college and career counselor.
3. Assist the client with meals.
4. Clamp and unclamp the indwelling catheter every 2 hours.
5. Discuss discharge placement with the parents.
6. Emptying the trash can.
GOD BLESS US
ALL. SEE YOU
TOMORROW!!!