Potter: Fundamentals of Nursing, 8th Edition

Chapter 21: Managing Patient Care Case Study with Answers Ms. Liz Osborne is being admitted to the medical-surgical unit for acute symptoms of anemia. She is a 27-year-old schoolteacher. She has been on a juice diet for the past month to help her lose weight before her wedding and has been experiencing fainting spells, weakness, shortness of breath, and leg cramps. Jay is the student nurse who has been assigned to admit Ms. Osborne. He is in his last semester of nursing school and is preparing to take the NCLEX-RN examination. Because of this, he is anxious to finish his shift so he may go home to study. 1. Jay begins to plan Ms. Osbornes care and decides to delegate Ms. Osbornes assessment to the nursing assistant because he is behind on his patient rounds. It is acceptable for Jay to delegate the task of assessment according to the American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN). A. True B. False Answer: B Rationale: The nurse does not delegate the steps of the nursing process of assessment, planning, and evaluation because these steps require nursing judgment according to the ANA and NCSBN. 2. Jay delegates the task of taking vital signs to a new nursing assistant on the unit with whom Jay has never worked before. Which of the following questions asked of the new nursing assistant will help Jay determine that it is safe to delegate the task of taking vital signs? (Select all that apply.) A. How long should you keep the thermometer in the patients mouth? B. How do you apply a blood pressure cuff to an obese patient? C. How do you take a patients pulse? D. Do you know how to take vital signs? Answer: A, B, C Rationale: Open-ended questions elicit a conversation and details to help the nurse assess the knowledge and skills on the nursing assessment. The question Do you know how to take vital signs? is a closed-ended question that does require further exploration. 3. Before Jay delegates tasks, he must make sure that he is delegating in accordance with a registered nurses legal scope of practice. Rank in order the five rights of delegation Jay must follow. A. Right supervision/evaluation B. Right person

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C. Right task D. Right circumstances E. Right direction/communication Answer: C, D, B, E, A Rationale: The five rights of delegation are right task, right circumstances, right person, right direction/communication, and right supervision/evaluation.