COMPLETE QUESTIONS AND CORRECT
ANSWERS GRADED A PLUS
◉ Prior to delegating client care, consider the following..
Answer: Predictability of outcome ●Will the completion of the task
have a predictable outcome? ●Is it a routine treatment? ●Is it a new
treatment? Potential for harm ●Is there a chance that something
negative can happen to the client (risk for bleeding, risk for
aspiration)? ●Is the client unstable? Complexity of care ●Are
complex tasks required as a part of the client's care? ●Is the
delegatee legally able to perform the task and do they have the skills
necessary? Need for problem solving and innovation ●Is nursing
judgment required while performing the task? ●Does it require
nursing assessment skills? Level of interaction with the client ●Is
there a need to provide psychosocial support or education during
the performance of the task?
◉ Examples of tasks nurses can delegate to practical nurses and
assistive personnel.
Answer: TO PN Monitoring findings (as input to the RN's ongoing
assessment)Reinforcing client teaching from a standard care
planPerforming tracheostomy careSuctioningChecking NG tube
patencyAdministering enteral feedingsInserting a urinary
catheterAdministering medication (excluding IV medication in some
,states). TO AP Activities of daily living (ADLs) Bathing Grooming
Dressing Toileting Ambulating Feeding (without swallowing
precautions). Positioning Routine tasks. Bed making. Specimen
collection Intake and output Vital signs (for stable clients).
◉ Right direction/communication (five rights of delegations).
Answer: Data that needs to be collected ●Method and timeline for
reporting, including when to report concerns/findings ●Specific
task(s) to be performed; client-specific instructions ●Expected
results, timelines, and expectations for follow-up communication
RIGHT DIRECTION AND COMMUNICATION: Delegate an AP to assist
the client in room 312 with a shower before 0900 and to notify the
nurse when complete.
WRONG DIRECTION AND COMMUNICATION: Delegate an AP to
assist the client in room 312 with morning hygiene.
◉ Steps in providing educational programs.
Answer: 1. Identify and respond: Determine the need for knowledge
or skill proficiency 2. Analyze: Look for deficiencies, and develop
learning objectives to meet the need 3. Research: Resources
available to address learning objectives based on evidence-based
practice 4. Plan: Program to address objectives using available
resources 5. Implement: Program(s) at a time conducive to staff
availability; consider online learning modules 6. Evaluate: Use
, materials and observations to measure behavior changes secondary
to learning objectives
◉ Tetralogy of Fallot..
Answer: Four defects that result in mixed blood flow: Pulmonary
stenosis, ventricular septal defect, overriding aorta, right ventricular
hypertrophy. Cyanosis at birth: progressive cyanosis over the first
year of life. Systolic murmur. Episodes of acute cyanosis and hypoxia
(blue or "Tet" spells knee chest position or squating). SURGICAL
PROCEDURES Shunt placement until able to undergo primary repair.
Complete repair within the first year of life.
◉ Defects that increase pulmonary blood flow.
Answer: Ventricular septal defect (VSD) (20.1) Atrial septal defect
(ASD), Patent ductus arteriosus (PDA),
◉ Defects that increase pulmonary blood flow Ventricular septal
defect (VSD).
Answer: _______ A hole in the septum between the right and left
ventricle that results in increased pulmonary blood flow
(left-to-right shunt) ●Loud, harsh murmur auscultated at the left
sternal border ●Heart failure ●Many VSDs close spontaneously
early in life.