E Handouts 1A 2023 Prioritizing and Delegation

The CURRICULUM DESIGNER for
ESTABLISHING today’s lessons:

PRIORITIES AND Dr. Ray A. Gapuz, MAN, DSc,RN
DELEGATION USRN (Illinois and Georgia)
HAAD RN Certified
PROMETRIC Certified
CGFNS Certified
Summa cum laude, UST

Boardtopnotcher, Rating : 89.20
OUR RULE #2
Avail of your FREE SIT IN and

MENTORING after our formal
class schedule.
NO. 1
CONCEPTS
1
Example: ➢ The nurse is reviewing a 68 year-old
Bowtie Item client’s assessment data to prepare the
client’s plan of care.
The following were noted:
Action to take Parameter to Monitor
Frequent orthostatic hypotension
Pounding heart beat
Diagnosis
Chest pain
Shortness of breath
Fatigue
Weakness
ECG tracing reveals
Example:
Bowtie Item STRATEGY
Identify the main topic: ECG pattern that leads to stroke
Atrial Fibrillation
Diagnosis
Irregular QRS and small P waves or F waves

Functional Concept ® Functional Concept ®

The 3 goals in the management of AF
Management of atrial fibrillation is include:
primarily focused on the 1. Control of ventricular rate 2. Minimize thromboembolism 3.Restoration and maintenance
of NSR
prevention of stroke and heart Oral

Verapamil
Oral
Aspirin
Oral
failure Digoxin
Metoprolol
Propranolol
Warfarin
Dabigatran
Quinidine
Flecainide
Propafenone
IV IV Amiodarone
Procainamide Heparin Disopyramide
Amiodarone Sotalol
FUNCTIONAL CONCEPT ® IS A REGISTERED TRADEMARK OF RAY A. GAPUZ TEST PREP SYSTEM FUNCTIONAL CONCEPT ® IS A REGISTERED TRADEMARK OF RAY A. GAPUZ TEST PREP SYSTEM
2
Functional Concept ® NCLEX QUICK FIX TIP
Drugs that may cause atrial
fibrillation includes:
ECG TRACING
M ilrinone
A tropine
denosine
D obutamine
FUNCTIONAL CONCEPT ® IS A REGISTERED TRADEMARK OF RAY A. GAPUZ TEST PREP SYSTEM
➢ The nurse admits a client complaining of Example:

frequently experiencing syncope, Bowtie Item
palpitation, lightheadedness and dizziness.
Further assessment reveals the following: Action to take Parameter to Monitor
Less than normal magnesium

Diagnosis
Less than normal potassium
Less than normal calcium
ECG tracing reveals

Priorities in the treatment of Torsades de
pointes include: Torsades de pointes may
1. Isoproterenol infusion progress to ventricular
2. Atropine IV
3. Magnesium sulfate IV (treatment of fibrillation.
choice)
4. Defibrillation when ventricular
fibrillation is present
3
The Ray A. Gapuz Test Prep System For The NCLEX RN
TORSADES DE POINTES Torsades de Pointes

Causes
P rolonged QT which are drug-induced ( clarithromycin,levofloxacin,

haloperidol,fluoxetine, cimetidine)
O ndansetron
I nherited traits
NO known cause (idiopathic)
T reatment with lithium and antiarrythmics
E lectrolyte imbalance: hypomagnesemia, hypokalemia, hypocalcemia
S ubstances from foods like grapefruit
5:59
The Ray A. Gapuz Test Prep System For The NCLEX
16 of RN
20
NCLEX QUICK FIX TIP 2nd degree AV Block- Type 1

✓There is progressive lengthening of the PR interval
and then failure of conduction of an atrial beat,
manifested by a dropped QRS complex.
ECG TRACING ✓Rhythm - Regularly irregular
✓P Wave - Ratio 1:1 for 2,3 or 4 cycles then 1:0.
✓Rate - Normal or Slow

✓P wave rate - Normal but faster than QRS rate
✓QRS Duration - Normal
5:59
The Ray A. Gapuz Test Prep System For The NCLEX RN The Ray A. Gapuz Test Prep System For The NCLEX
16 of RN
20
2nd Degree AV Block-type 1 2nd degree AV Block- Type 2

✓Atrial contractions are not regularly followed by
ventricular contraction thus there are P waves that
may not be followed by QRS complexes
✓QRS Duration – Prolonged
✓P-R Interval - Normal or prolonged but constant
✓Rhythm – Regular
✓Rate - Normal or Slow
✓P wave - Ratio 2:1, 3:1
✓P wave rate - Normal but faster than QRS rate
4
The Ray A. Gapuz Test Prep System For The NCLEX RN The Ray A. Gapuz Test Prep System For The NCLEX RN
2nd Degree AV Block-type 2 Type 1 Type 2

2nd degree FEATURE 2nd degree
Irregular Rhythm Regular
Normal or
Progressively
PR interval prolonged but
lengthened
constant
Normal QRS Prolonged
1:1 for 2,3 or 4
P wave ratio 2:1, 3:1
cycles then 1:0
The Ray A. Gapuz Test Prep System For The NCLEX RN
2nd degree type1 AV block Functional Concept ®

The symptoms of second and third
degree heart block include:
Fainting
F atigue
2nd degree type2 AV block D izziness
S hortness of breath
C hest pain
Asymptomatic patients with 2nd

A slow heart rate may be indicative degree heart block do not require
of complete heart block ! any specific therapy in the pre-
hospital setting.
5
Functional Concept ® NCLEX QUICK FIX
PRIORITIZING
Atropine sulfate is given in
complete heart block to increase PREGNANT CLIENTS
the heart rate.
Functional Concept ®
Priorities for MCN cases include:
C ardiac compromise A bnormal V/S
A cute mental status change
S evere respiratory distress P rolapsed cord
eizures
igns of abruptio placenta I mminent birth
igns of uterine rupture
H emorrhage Image from: "32 Weeks (8 Months Pregnant!)" by Pretty Poo Eater is licensed
under CC BY-SA 2.0”
Common Danger Signs in NCLEX QUICK FIX

Pregnancy
PRIORITIES
A- bsence of fetal movement (min:10/2 h)
P - ersistent vomiting beyond first trimester
P - elvic pressure
L - ow backache/leaking of fluid from vagina
/bleeding IN
NEWBORN CLIENTS
E - xcessive weight gain with swelling of fingers
or convulsions
S -evere abdominal pain or severe headaches
with blurred vision
6
Functional Concept ®
Guidelines from the Neonatal
Resuscitation Program (NRP)
recommends against
oronasopharyngeal suctioning with a
bulb syringe after birth.
Image from: "Berenguer La Newborn Expressions“

by teadrinker is licensed under CC BY-ND 2.0”
Evidence suggests that suctioning can

stimulate the vagus nerve which can There was no difference in RR between
lead to bradycardia. suctioning and wiping groups within
(Kelleher,J Bhat R, salas AA, et al., the first 24 hours of birth.
2013) (Kelleher, et al., 2013)
NCLEX QUICK FIX Functional Concept ®
PRIORITIZING Pediatric patients with iron
PEDIATRIC CLIENTS
deficiency anemia (IDA) must be
assessed for their diet !
7
Risk factors to lung cancer include the following:
PRIORITIZING CLIENTS MODIFIABLE
(You can change)
NON- MODIFIABLE
(You can not change)
UNCERTAIN
(Needs validation)
WHO ARE Tobacco smoke (leading)

Second hand smoke
Exposure to radon (leading in
Previous radiation therapy
Air pollution ( slightly increase
Smoking marijuana
E cigarettes
AT RISK FOR LUNG

the risk) Talc and talcum powder
non-smokers) Personal or Family history
Exposure to asbestos (genetics)
Exposure to uranium,
arsenic,beryllium,cadmium,silic
CANCER
a, vinyl chloride, nickel
compounds,chromium
compounds, coal products,
mustard gas,chloromethyl
ethers,diesel exhaust
Betacarotene supplements
Arsenic in drinking water
PRIORITIZING In the care of a patient with

dementia, reorientation is
PSYCHIATRIC the priority !
CLIENTS
NCLEX QUICK FIX Main Strategy

The 10 Common
PRIORITIZING Functional Concepts
STRATEGIES on
Establishing Priorities
8
PRIORITIZING STRATEGY 1 Rationale
REMEMBER
•Abdominal rigidity indicates

A manifestation that indicates a perforation of the bowels (a
complication is a nursing priority complication).
•Fever, bloody diarrhea and

abdominal pain are expected
manifestations of ulcerative colitis

•INR- International Normalized Ratio ( formula
patient PT/control PT) or the PTT-Partial
An abnormal laboratory data is a Thromboplastin Time (normal: 60-70s) is
monitored for a client taking heparin
nursing priority !
•PT- Prothrombin Time is monitored for a client
taking warfarin sodium (Coumadin)
•Bleeding time and clotting time are non-specific
test for coagulation abnormalities

•Fever that develops within 20
When a complication minutes of blood transfusion
develops during a indicates a complication –pyrogenic
procedure, discontinue reaction.
the procedure !
Any complication that develops
during a procedure requires
discontinuing the procedure.
9
•Jaundice that occurs in a client taking
antipsychotics indicates hepatotoxicity.
Any adverse effect of a drug
•It is expected that valium causes
related to the kidneys and liver drowsiness. The normal serum level of
is a nursing priority ! digoxin is 0.5 to 2.5, so a level of 1.9 is
normal. Methergine causes elevation of
BP, so a BP of 130/90 is expected

Admission priorities:
shock Tachycardia with hypotension
cardiac arrest indicates shock, which is a nursing
anaphylaxis priority
multi system trauma
eclampsia

To make way for a vacant bed during
major disasters, consider •A client post ultrasound is not
discharging the following clients required to be bedridden, so the
who : client can be discharged.
3D
elivered 24 hours ago
ue for discharge within the day
one with a diagnostic test and
is not bed ridden
10
A client with multiple sclerosis with
A client with ongoing ongoing IV treatment is a priority for
treatment is a nursing priority the nurse to visit.
A medical-surgical case is Laryngeal obstruction is a medical

a nursing priority over a case that can lead to airway
psychiatric case obstruction.

An acute condition is a nursing
An acute condition is a priority.
nursing priority
Acute pancreatitis is an example of a
condition that is a priority.
11
REMEMBER
A client with a surgical incision near
the diaphragm is a nursing priority The surgical incision of a post-
cholecystectomy client is nearest the
diaphragm. This may lead to altered
breathing patterns.
Think ABC !
Remember
NO. 2
Think MACS
1. Maslow says physiologic needs
first
2. ABC
3. Complications- Acute first
4. Signs indicative of worsening
STRATEGY
➢For each task, click to specify whether it is
Question and Answer agreement: Note the phrase “post-partum unit”
appropriate for the RN,LPN and UAP:
Task RN LPN UAP
Initiate blood Services at the postpartum unit

transfusion
Monitor IV fluids
Can be extended to clients with surgery of

Phlebotomy
the reproductive organs
Administer insulin to a
home care resident
Administer heparin
Therefore, a client post hysterectomy can be
Administer drugs via transferred to the post partum unit
gastrostomy
12
Five interventions implemented to prevent falls
(physicians, PT, RN, food service staff, housekeepers
FUNCTIONS of the and family members):
1. Put bed in low position
UNLICENSED ASSISTIVE 2. Keep room free of clutter
3. Have personal items and call light within reach
PERSONNEL 4. Maintain adequate lighting
5. Call for help if assistance is needed
FUNCTIONAL CONCEPT ® IS A REGISTERED TRADEMARK OF RAY GAPUZ REVIEW SYSTEM
The RN completes the inventory of the

Pain, position and potty are the three
clients personal items brought to the
common reasons for the clients
hospital. For those that need to be
activation of a call light.
bagged, the UAP does this.
PRIORITIZING The RN and the LPN may delegate the
&
technical task of medication
administration to the UAP
DELEGATION
13
Delegation of medication administration to
All on-going assessments, appropriately educated and competent UAP
includes the following routes:
interpretations, judgments and P Pills (oral), powder and paste
decision-making required relative to O Oral, opthalmic, otic
I Inhalant
clients receiving medications must be N Nasal drops and sprays
carried out by the RN. T Topical, transdermal
S Sublingual, buccal, suppositories (vaginal)

IV, intraosseous,epidural/caudal,
ID, SQ and IM may be delegated to intrathecal, intraoral,cranial
the UAP, ONLY with careful intraventricular administration of
considerations of applicable laws. medications are NOT permitted for
delegation to the UAP.

The following may not be delegated to the UAP: The UAP are responsible for:
Recognizing side effects, toxic effects, allergic
reactions, immediate desired effects, unusual and Documenting all medication
unexpected effects, changes in clients condition administration
that contraindicate administration for the drug,
making judgments Reporting to the delegating nurse all
deviations in client condition or
medication administration
14
A client who is receiving a stat dose A client who is manifesting an

of medication should be considered a adverse effect of a drug should not
priority over clients who are receiving be delegated.
maintenance medications

In the care of the client with impaired speech,
the UAP should:
1. Listen attentively
2.
3.
Need to be familiar with the clients speech pattern
Ask the client to repeat or rephrase statements if needed
The use of communication boards is
4.
5.
Ask the client to write down key words
Watch the client’s lip movements
intended to facilitate communication
6. Observe non-verbal cues ( facial expressions, gestures, body
language)
with clients with speech difficulties.
7. Use open-ended questions and avoid close-ended questions
8. Avoid completing sentences for the client unless the client exhibits
fatigue
9. Use communication board
10.Reinforce instructions from the speech therapist

In caring for a non-English speaking client, the In the care of the client with dysphagia, the
UAP should: UAP should:
1. Prepare the client at meal time
2. Assist with feeding
1. Use communication board 3. Measure, report and record intake
2. Utilize sign language/gestures 4. Measure and record height and weight
3. Ask the help of an interpreter 5. Report any of the following to the RN:
4. Consult language resources for common - difficulty chewing
- difficulty swallowing (increasing)
words and phrases - vomiting
- changes in appetite or eating habits
- weight loss/gain
- chest or abdominal discomfort
15
In the care of the client with hearing
impairment, the UAP should:
The UAP may feed the dependent 1. Gain the client’s attention and inform the client of your presence
2. Face the person
client ! 3. Ensure sufficient light
4. Speak in a normal tone of voice
5. Avoid over enunciating words
6. Use short sentences and simple words
7. Minimize background noise
8. Speak to the better ear
9. Use communication board or hand gesture or sign language
10. Repeat or rephrase statements as needed using different words to
vary pitch
Functional Concept ® NCLEX QUICK FIX

In caring for a client with hearing aid,
the UAP should:
1. Discuss and demonstrate how to
care for the hearing aid DELEGATION
2. Demonstrate how to insert and
remove batteries
3. Demonstrate how to insert and
remove the hearing aid

RNs can:
When delegating a task, consider: Initiate and administer blood to a client
Administer high-risk medications including
Scope of practice required for the task heparin and chemotherapy
Complexity and predictability of the task Give meds through IV and IV push
Potential for harm Monitor and titrate medications independently
Level of critical thinking required to perform the Perform tasks that may be performed by LPNs and
task UAPs
16
LPNs can: LPNs can:
Assist the RN Administer oral medications
Assist in collecting data and monitoring client Administer enteral feedings
findings Give NG tube feedings and check NGT patency
Reinforce client teaching Change wound dressings
Delegate to UAPs May monitor blood products BUT NOT initiate it
Perform tracheostomy care and suctioning
Insert urinary catheter

LPNs can NOT:
LPNs with certifications can: Administer high risk medications (heparin and
Monitor and maintain IV infusions chemotherapy)
Administer IV medications through Administer IV push
Titrate medications
piggy back Independently provide patient education
Perform or document admission, or discharge of
patients

UAPs can NOT:
UAPs can: Perform assessment and patient education
Perform phlebotomy except arterial punctures Delegate tasks
Check vital signs Administer medications, tube feedings, change
Monitor I and O wound dressings
17
Remember
Remember these:
1. A,T,E for the RN
2. ADL for the UAP
3. CST- chronic, stable , in traction
can be delegated
4. Routine, Unchanging, Standard
procedures can be delegated
18

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The CURRICULUM DESIGNER for

ESTABLISHING today’s lessons:

Summa cum laude, UST

Avail of your FREE SIT IN and

Irregular QRS and small P waves or F waves

Functional Concept ® Functional Concept ®

prevention of stroke and heart Oral

FUNCTIONAL CONCEPT ® IS A REGISTERED TRADEMARK OF RAY A. GAPUZ TEST PREP SYSTEM

➢ The nurse admits a client complaining of Example:

Less than normal magnesium

ECG tracing reveals

Functional Concept ® Functional Concept ®

TORSADES DE POINTES Torsades de Pointes

P rolonged QT which are drug-induced ( clarithromycin,levofloxacin,

NCLEX QUICK FIX TIP 2nd degree AV Block- Type 1

✓Rate - Normal or Slow

2nd Degree AV Block-type 1 2nd degree AV Block- Type 2

2nd Degree AV Block-type 2 Type 1 Type 2

The Ray A. Gapuz Test Prep System For The NCLEX RN

2nd degree type1 AV block Functional Concept ®

FUNCTIONAL CONCEPT ® IS A REGISTERED TRADEMARK OF RAY A. GAPUZ TEST PREP SYSTEM

Functional Concept ® Functional Concept ®

Asymptomatic patients with 2nd

FUNCTIONAL CONCEPT ® IS A REGISTERED TRADEMARK OF RAY A. GAPUZ TEST PREP SYSTEM

FUNCTIONAL CONCEPT ® IS A REGISTERED TRADEMARK OF RAY A. GAPUZ TEST PREP SYSTEM

Common Danger Signs in NCLEX QUICK FIX

Image from: "Berenguer La Newborn Expressions“

Functional Concept ® Functional Concept ®

Evidence suggests that suctioning can

NCLEX QUICK FIX Functional Concept ®

PRIORITIZING Pediatric patients with iron

FUNCTIONAL CONCEPT ® IS A REGISTERED TRADEMARK OF RAY A. GAPUZ TEST PREP SYSTEM

WHO ARE Tobacco smoke (leading)

AT RISK FOR LUNG

NCLEX QUICK FIX Functional Concept ®

PRIORITIZING In the care of a patient with

NCLEX QUICK FIX Main Strategy

•Abdominal rigidity indicates

•Fever, bloody diarrhea and

PRIORITIZING STRATEGY 2 Rationale

PRIORITIZING STRATEGY 3 Rationale

PRIORITIZING STRATEGY 5 Rationale

PRIORITIZING STRATEGY 6 Rationale

PRIORITIZING STRATEGY 8 Rationale

A medical-surgical case is Laryngeal obstruction is a medical

PRIORITIZING STRATEGY 9 Rationale

Initiate blood Services at the postpartum unit

Can be extended to clients with surgery of

FUNCTIONAL CONCEPT ® IS A REGISTERED TRADEMARK OF RAY GAPUZ REVIEW SYSTEM

Functional Concept ® Functional Concept ®

The RN completes the inventory of the

NCLEX QUICK FIX Functional Concept ®

PRIORITIZING The RN and the LPN may delegate the

Functional Concept ® Functional Concept ®

Functional Concept ® Functional Concept ®

A client who is receiving a stat dose A client who is manifesting an

Functional Concept ® Functional Concept ®

Functional Concept ® Functional Concept ®

Functional Concept ® NCLEX QUICK FIX

Functional Concept ® Functional Concept ®

Functional Concept ® Functional Concept ®

Functional Concept ® Functional Concept ®

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