Case Study: Delegation Fund – NCLEX-RN®

by Rhonda Lawes, PhD, RN

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    00:00 Hi, I'm Professor Lawes, and in this one, we're gonna go over the Next-Gen Case Study format.

    00:06 Now, I'm really excited to do this with you.

    00:09 It is not nearly as bad as you're probably thinking it's going to be.

    00:13 So, let's get started.

    00:17 Now, we always started presentations with a beautiful picture.

    00:20 These won't be on the NCLEX.

    00:22 What I want you to do though, is to get in the habit of picturing and imagining what's going on with your patient.

    00:29 Picture the setting, picture the people, picture the patient, build all these things in your mind.

    00:36 It's not just a silly exercise, it will really help you focus your brain and not make what we call those silly mistakes.

    00:44 So let's get started.

    00:46 The nurse is assigned to provide care for a client with the team support of a licensed practical nurse and an unlicensed assistant personnel.

    00:56 Hey, wait a minute.

    00:58 This is spelling out a whole lot of people.

    01:02 They're being very specific here that you're the RN, you have an LPN and a UAP.

    01:10 This tells me you're likely going to have some delegation questions somewhere in this case study.

    01:15 So you'll probably have some physical questions about their health and their vital signs.

    01:20 But you're also going to have some questions about delegation.

    01:23 Now, in my experience of teaching nursing schools, I have noticed that this is a challenge for nursing students, it's often not covered in detail very much in your courses.

    01:35 So we want to give you some pointers here before we even get into the case study.

    01:40 Whenever you see the titles listed in a question, you always want to ask yourself, "Who am I in the question?" And on the NCLEX exam, you will be the RN.

    01:51 Who are the other people? Well, here we've got an LPN and a UAP.

    01:57 The next question, do I delegate or supervise them? And if you're the RN, the answer is yes.

    02:04 Okay, so when I see these titles, I ask, "Who am I?" The answer is the RN.

    02:10 Who else is in the question? LPN and UAP.

    02:13 Do I delegate and supervise them? The answer is yes.

    02:18 Now you're thinking, "Come on Prof Lawes, of course, we do the LPN.

    02:21 No, other delegation questions, we'll list options like nurse manager or your peer.

    02:28 On the NCLEX exam, I do not delegate and supervise my peer.

    02:32 If there's a problem with my peer, then I go to my supervisor, and my supervisor will talk to the peer.

    02:39 And this one, we're dealing with people and team members that the RN directly supervises.

    02:46 But when you see those other questions, and they have people you don't directly delegate or supervise, it will change the answer to the question.

    02:53 Okay, so you got it.

    02:55 In this one, we've got an LPN, which some of you may know as an LVN, a licensed vocational nurse, and a UAP which in your hospital setting might be a tech or an aide or a CNA any of those titles.

    03:08 But in NCLEX language, you'll likely see LPN, LVN, and UAP.

    03:14 Now, let's get started into this question.

    03:16 Remember, use your mind to picture what's going on and the setting that we're in.

    03:23 So first of all, in a case study, you're going to see on your screen, the nurses notes.

    03:28 Now, this is something that you see, throughout these NGN type questions or these case study questions, you also see them on the bowtie.

    03:37 So let's take a look at what we have.

    03:39 This is the place I want you to stop.

    03:43 And take a deep breath because the worst thing you could do for yourself is to panic because you're in one of those case study questions.

    03:51 So let's take a look at what we have.

    03:53 I've got an older adult, and they present with drowsiness, dry skin, dry mucous membranes, blurred vision and confusion on the situation.

    04:04 Okay, anytime we're going through that, that's a lot of assessment information.

    04:08 So you want to go back up and say, "Is it normal or abnormal?" So anytime a patient communicate something to you either with their words or with the symptoms that they're showing you that's really important to focus your brain on.

    04:22 So we know they're older, okay.

    04:25 They have drowsiness.

    04:27 Well, nothing in this question up to this point has told us why they should be drowsy.

    04:32 It's not like they're waking up from anesthesia.

    04:34 That would be like making a whole story that isn't there.

    04:36 So we're going to assume anything aside from awake, alert and oriented is not normal.

    04:43 So drowsy, that's not normal.

    04:46 Dry skin? Well, that seems kind of odd that we would notice it that's not really normal either.

    04:51 Dry mucous membranes? That's not normal, blurred vision, not normal, and confusion, again, not normal.

    05:02 Now, here's a key note about older clients.

    05:04 On the NCLEX exam, just because you have an older client, doesn't mean it's okay for them to be confused.

    05:11 I teach students that with any elderly person, don't just assume that they're confused, ask why they're confused.

    05:19 Look at all the information in the data and see if there's something that's causing that confusion, just don't take it at face value.

    05:26 So, we've established, we have an older client, and they've got some abnormal assessment.

    05:31 Now let's look at their history.

    05:33 Okay, they have coronary artery disease, diabetes type 2, hypercholesterolemia which means they've got high cholesterol in their blood, hyper cholesterol and emia, high cholesterol in the blood, and hypertension, elevated blood pressure.

    05:52 Okay, so when I first looked at these nurses notes, I took a deep breath until myself, "Of course, you can do this just slow down and be thorough." I know that the abnormal assessments in the beginning portion.

    06:04 And next, I know their history.

    06:06 So now let's start to put all of these things together and see what it's going to ask us.

    06:13 First up new information, we're gonna take vital signs.

    06:16 So you look at the vital signs that we have there.

    06:19 And you ask yourself three questions.

    06:21 Is it high, low or normal? Okay, heart rate, 100 beats/min.

    06:28 Okay, that's still technically within the normal, right? 60-100 is still within normal.

    06:36 But that's a little high, most people don't run 100 beats.

    06:39 So I'm going to keep my eye on that.

    06:41 Blood pressure, whoa, yes, that's high.

    06:45 Even though the patient may be living with that, this is really too high, we'll get that diastolic 102.

    06:53 That's when that heart gets reperfused.

    06:55 So 102 is not acceptable, we're going to want to do something about that.

    06:59 And we'll consider that as we go forward.

    07:02 168 is also too high.

    07:05 Remember, this patient on top of everything else is diabetic.

    07:09 And we want them to have an even lower blood pressure than what we used to say, we used to say 140 but now we're cranking it down to like 130 or lower.

    07:18 So this is way too high.

    07:20 Respiratory rate 20, that's normal.

    07:23 Temperature? That's normal.

    07:26 So I have a heart rate that's a little high, a blood pressure that is too high, respirations, they're a little fast, but I'm not so worried about it.

    07:34 And temperature is normal.

    07:36 Okay, that's what we're looking at, is there any connection to those vital signs and what we know about this patient already? So you want to think those through, think if you have any connections.

    07:48 Now let's keep moving on through this study.

    07:52 All right, what you see on the screen is very similar to what you'll see when you're taking the NCLEX.

    07:57 We've already talked about the question, we've looked at the nurses notes.

    08:01 But I want you to stop for just a minute and kind of look at the format here.

    08:05 So when you're taking a test, this might seem intimidating to you because it's got tabs.

    08:10 Don't worry about it.

    08:11 It's just the same strategies that we have walked through.

    08:15 So you see, the first tab is nurses notes.

    08:18 And behind that tab are vital signs.

    08:21 Now as you and I are walking through this case study, we're going to blow that up so it's easier for you to see.

    08:26 But I want you to be very comfortable that this is the format that you'll see the question on when you're actually taking the NCLEX.

    08:33 You've got the information on the left, black bar through the middle, and you'll have questions that pop up on the other side.

    08:40 Okays? So don't let this intimidate you.

    08:43 It's just a different way to present questions that you're used to answering.

    08:47 It's just the format that looks a little different.

    08:50 So when you click on the tab, you see we have nurses notes, but if you click on the second tab, you'll see that we have the vital signs.

    08:57 All right. So clicking back and forth, you can click as many times as you want.

    09:03 You can go back and forth as often as you need to, but don't hyper focus on this.

    09:08 Just do your best to be thorough as you work through it like we did when we walk through these and keep moving through the case study.

    09:17 Now you see on the right hand side, you've got some directions and that's what it'll look like when you're taking the NCLEX.

    09:23 So take a look at those directions.

    09:25 It is telling you to click to highlight below the findings that are concerning to the nurse.

    09:31 Okay, here's why this matters to you.

    09:34 The first time I tried all these questions, I was really nervous.

    09:37 Do you know what I was worried about? What if I miss one tiny word? What if I don't check something that they wanted me to check and I do check something...

    09:45 You don't need any of that stress.

    09:47 How the test is set up is there's only certain terms that can be highlighted.

    09:53 So don't let that stress you out.

    09:55 You'll see that they're here in the same question.

    09:57 Now where does all this wording come from? That's the nurses notes.

    10:02 We saw those on that previous tab.

    10:05 So you don't need to read it again because you're very familiar with what this is.

    10:10 But when you're thinking through the question, go through it word by word.

    10:14 Now remember, we noted that drowsiness, dry skin, dry mucous membranes.

    10:19 Those are all abnormal, blurred vision is abnormal.

    10:22 That's why you spent that much time kind of walking through those nursing notes the first time you looked at them.

    10:28 So let's see what we should highlight and what we don't need to.

    10:32 So the first one is drowsiness, dry skin, dry mucous membranes, they've kind of got those all together.

    10:41 Now, first of all, I know that's abnormal assessment.

    10:44 Should that be concerning to me, though? Well, based on the patient's history of diabetes, that's why I'm concerned.

    10:52 So the drowsiness could be a sign of high blood sugar.

    10:56 The dry skin and dry mucous membranes could also be a sign of the dehydration that can come along with a high blood sugar.

    11:04 When your blood sugar is high, then you end up urinating a lot.

    11:09 And you end up dehydrated, dry skin, dry mucous membranes is an indication of dehydration which is not a good sign for a diabetic client, because it might be because of their high blood sugar.

    11:22 Now, other things can cause it but you can see all these clues are kind of pointing to one perspective.

    11:29 Blurred vision, also associated with high blood sugar.

    11:34 Now, lastly, we've got confusion on the situation on this line.

    11:38 Okay, so we know that we've already checked drowsiness, dry skin, dry mucous membranes, blurred vision, those are all things that we say yes to highlighting.

    11:50 Now, confusion on the situation.

    11:53 That's also a sign of a high blood sugar and confusion here is telling us this is a change.

    11:59 So we would highlight that.

    12:01 Now we've got some others history of coronary artery disease, and hyper cholesterol.

    12:08 Now, I know they've got these plays together.

    12:10 But we're thinking about these types of questions like, what's impacting the situation right now? Does coronary artery disease play a role? Sure. But I'm not really going to resolve that or fix that here in this situation.

    12:22 High cholesterol? Well, that's not great.

    12:25 But that's more of a long term problem.

    12:28 So we're left with diabetes and hypertension.

    12:31 Should those be concerning? Yes, we're going to highlight those because diabetes is likely what's giving us all this confusion and blurred vision, we walk through that.

    12:41 So we know they're going to need probably some better or more effective blood glucose monitoring, and hypertension, we already established that blood pressure is too high.

    12:52 So pause for a minute, take a look at the screen, see the terms that we highlighted and see if you can explain to yourself why we highlighted those.

    13:02 After that, look at the ones we chose not to highlight and see if you can explain why we didn't highlight those.

    13:12 Okay, you did a great job.

    13:15 You've made it through the first part of the case study.

    13:19 You feel better? Now but that is all the way done.

    13:23 Well, let's go back to what it looks like on your screen.

    13:27 So you see that we're on the left side, we have the stem of the question.

    13:30 We have the nurses notes under one tab, the vital signs on the other.

    13:34 Now we've got the next question in the case study format.

    13:37 It says the client is at risk for experiencing what condition.

    13:41 Now we have 1, 2, 3, 4, 5 options there.

    13:47 This one is you're really going to select all that apply.

    13:51 So you can't just look for the right answer and then go on to the next one.

    13:54 So we're gonna work through these.

    13:56 There's a lot of H's there which has absolutely nothing to do with the question.

    14:01 Alright, so that's not a strategy for NCLEX.

    14:03 It's just something my squirrel brain notice as we're looking at these.

    14:07 So the first one, hypoglycemia.

    14:10 Do I think this patient is experiencing hypoglycemia? Well, if you have low blood sugar, what do I know the symptoms are? Fast heart rate, I know they're gonna be shaky and irritable and no, those don't really sound like this patient so I am not going to check hypoglycemia.

    14:30 Hyperglycemia, well, that means high blood sugar.

    14:34 Well, I've already established they're drowsy, right? They're dehydrated.

    14:39 They're confused.

    14:40 Yeah. The sound more like hyperglycemia? I'm going to check hyperglycemia.

    14:46 Heat exhaustion.

    14:49 Where did that come from? That stuff's gonna happen to the NCLEX all the time.

    14:54 Heat exhaustion, you would have to have a really high temperature.

    14:58 Look at the temperature, you see there, it's within normal limits.

    15:02 So, yes, they would probably be dehydrated with heat exhaustion or they would be dehydrated or heat exhaustion, but their temperature would have to be a lot higher.

    15:10 So I am not going to select heat exhaustion.

    15:14 So, so far of the first three, I have selected hyperglycemia.

    15:18 Does that still make sense? Yes, it does.

    15:21 Now, diabetic ketoacidosis that's DKA.

    15:27 Now that predominantly happens with type 1 diabetics.

    15:31 In this client, are they type 1 or type 2? Right, they're type 2.

    15:38 See what if you couldn't remember which one they were, all you'd have to do is click on that tab that says nurses notes and you can bring that right back up again.

    15:46 Okay, so we've got DKA.

    15:48 Nope, this patient is a type 2 diabetic and not likely to be diabetic ketoacidosis.

    15:56 Now, the last one, see it right there? Hyperglycaemic hyperosmolar syndrome, HHS.

    16:04 Does that happen with type 2 diabetes? Yes. I mean, it takes a while to develop over time, it happens, you have a really high blood sugar, all those symptoms, your body's going to dump all fluids trying to figure out what is going on trying to maintain homeostasis because of that super high blood sugar.

    16:25 So yes, that is a possibility.

    16:28 Now what I want you to do is to go back and to look at the ones that we have checked. Right? Which one are the ones that we have checked and said, "Yes, I'm going to highlight these." We checked hyperglycemia and HHS? Does that make sense with what we know to be true about this patient's symptoms and their history? It does.

    16:52 We gave sound rationale for why it was not hyperglycemia, heat exhaustion, or DKA.

    16:58 So then you say I feel comfortable with this.

    17:01 I worked through this in a systematic manner.

    17:03 I'm going to keep moving on.

    17:07 All right, now let's take a look at the third part of this case study.

    17:12 See on the left hand side of your screen, you have those tabs, you have the black bar down the middle.

    17:17 And on the right side, you've got the third type of question in the same case study.

    17:22 Now you'll see that we've got some notes on the left hand side, it says, "A serum blood glucose is pending." So we don't know what it is right now.

    17:32 But it's asking you there the nurse will delegate to the LPN the task of and then you've got that box with a drop down arrow.

    17:40 Well, below that you've also got the nurse will delegate the task of to the UAP.

    17:46 So what we're gonna do in this question is figure out what's most appropriate to delegate to an LPN and to a UAP? Who am I in the question? I'm the RN.

    17:55 Now I want to show you what it looks like when you're taking the test.

    17:58 I just want to show you visually what it will look like on the screen.

    18:01 When you click that drop down arrow, you see that? You've got three options.

    18:06 Let's do it again on the second question, just so you have a feel for what it'll look like.

    18:11 All right, now let's break down the question.

    18:12 We're going to blow everything up bigger.

    18:15 So you and I can work through it and talk through it together.

    18:17 But I want you to keep in mind, this is the format that you'll see on the NCLEX exam when you're taking the actual test.

    18:24 So we know that a serum blood glucose is pending.

    18:28 Now let's do, first we've got the nurse will delegate to the LPN the task of.

    18:34 Okay, so what are our options? We can first option is reinforcing the diabetic diet, we can do reporting the blood glucose over 300 to the nurse and entering the admission data.

    18:51 Okay. So I know who I'm delegating to is the LPN.

    18:56 So I'm looking for something that's most appropriate for the LPN.

    19:00 Now, we've got reinforcing the diabetic diet, could they do that? Oh yeah, there's a key word they're reinforcing.

    19:09 Now, initial assessment is an RN only scope of practice.

    19:13 Teaching is an RN only scope of practice.

    19:17 But reinforcing what the RN has taught is fine.

    19:21 So reinforcing the diabetic, the LPN can do that.

    19:24 So that's a likely a probable answer for us.

    19:27 But let's look at the other ones, just in case, right.

    19:30 You always want to do that.

    19:32 Even if you think the first answer that has got to be the right answer, make yourself do the work to eliminate the other answers to be extra cautious in selecting the right answer.

    19:43 So second option for the LPN reporting a blood glucose over 300 to the nurse.

    19:51 Okay, could an LPN do that? Well, it seems like they could, but you would want to report all the blood glucose readings to the RN, not just those over 300.

    20:04 If you're waiting to report a blood glucose until it's over 300, we're really getting into some problem territory.

    20:10 So I like number one better.

    20:12 And sometimes, that's all you can do.

    20:15 You can take a look at the answer and see, "Oh, I'm not essentially clear on that." But number 1 seems like a much more straightforward task that on the NCLEX exam would be appropriate for an LPN.

    20:27 So because the first option is more appropriate than number 2, I'm going to rule out number 2.

    20:33 Now the last one entering the admission data.

    20:38 Okay, now, that's not appropriate for the LPN.

    20:40 The nurse, the RN will enter the initial admission data.

    20:44 So when I look at these three options, the most appropriate one, the most clear, standardized task of these three would be reinforcing the diabetic diet.

    20:56 That's what I would check for the first one.

    20:58 So in the drop down arrow, that's the one I would select.

    21:01 Now move on to the second part of the question, the nurse will delegate the task of blank to the UAP.

    21:08 Okay, so that's like a CNA or a tech.

    21:10 This isn't we've got what should the nurse delegate to them? Well, the LPN has a larger scope of practice than the UAP does.

    21:19 Let's take a look at what our options are.

    21:22 Okay, assessing urine color during I & O.

    21:25 Well, the your UAP can they can report any unusual colors like and we would want them to.

    21:31 If they're looking at the patients here, and they notice, like, "That's not normal." You would definitely want them to tell the LPN and the RN, but the actual assessment of the color would have to be done by an RN, that's within their scope of practice.

    21:47 So here's a clue on the NCLEX.

    21:49 A UAP, or an LPN can recognize normal and abnormal, anything beyond that, if it's abnormal, they need to report it to the RN, and the RN has to come in and do an assessment.

    22:01 So when you see the word assess with an LPN or a UAP, make sure you're very careful with that is that is typically part of the are in scope of practice.

    22:11 So we're back to you.

    22:12 What about this? Would this work for UAP? Recording the vital signs.

    22:17 Oh yeah, that's fine.

    22:19 A UAP can obtain the vital signs and record them, here's when they can't.

    22:24 If it's a new admit, they cannot do that, because that's part of an initial assessment.

    22:29 And coming into your unit, as an brand new patient, you've never met them before, that's an admit.

    22:35 But so your patient goes for an exam, like they go for a heart cath, and they come back, or they go for a CAT scan, and they go back.

    22:42 In NCLEX world, the RN needs to go into the room, assess the patient and taking initial vital signs upon the patient's return to the unit is only for an RN.

    22:52 I wonder your NCLEX exam because I think we all know, in real practice UAPs do this all the time, however, we're talking about how to you pass the NCLEX? And that's what we're focused on today.

    23:04 So could they record the vital signs as UAP? Yep, sure could.

    23:09 Let's not forget option number 3, though, monitoring the IV fluids.

    23:15 Now, that's kind of odd, right? Because UAPs can't start IVs.

    23:20 They can't hang IVs, they can't adjust the rate of IVs.

    23:23 So this would have to less likely be monitored by an RN.

    23:28 Now, in some states, an LPN might be able to do that, but always err on the side of extra safety.

    23:35 So between assessing the urine color during I & O, recording vital signs and monitoring the IV fluids, which one do you think is the most straightforward option within the safe scope of practice of a UAP? You got it.

    23:51 It's recording the vital signs.

    23:54 So take a look at the screen.

    23:55 You see there, we finished those answers.

    23:57 The nurse will delegate to the LPN the task of reinforcing the diabetic diet.

    24:03 The nurse will delegate the task of recording the vital signs to the UAP.

    24:07 Does that make sense? Sure, it does.

    24:11 And that's it.

    24:12 We're done with the third part of these questions.

    24:15 Now, let's move on to the fourth kind of section of this case study.

    24:19 You've got physicians orders.

    24:21 So it says, start normal saline fluid at 200 miL/hour.

    24:25 Start insulin analogue regular at 0.1 U/kg/h.

    24:30 And titrate down using the titration scale.

    24:33 And that would be something that would be typical in the hospital where you're practicing.

    24:37 Monitor urine output.

    24:39 And perform urine dipsticks and blood glucose testing.

    24:43 Okay, so your dipstick is when you take a stick and legitimately dip it in a patient's urine.

    24:49 They'll kind of tell you what's going on.

    24:51 And then blood glucose testing.

    24:54 In this case, would be a finger stick blood sugar.

    24:56 That's what we're looking at there.

    24:58 Okay, so you got it.

    24:59 You're in dipstick, fingerstick blood sugar, that's what we have moving forward.

    25:03 Now, what you have on your screen is exactly what it will look like when you're taking the NCLEX exam.

    25:10 This is starting to be familiar, isn't it? On the left side, you see information about the patient, a bar separating it.

    25:17 On the right side, you got the question that we're going to answer.

    25:21 So looking at the left side, these are the things you and I have already walked through, look through the right side and you see which question we're going to address.

    25:31 Now, let me read that for you.

    25:33 For each anticipated task, which tasks can the RN consider to be delegated to the LPN by indicating whether the statement exemplifies a task within the LPN scope of practice or is not within the LPN? You know, I'm telling you, when I'm stressed, and when I'm taking a test, I'm always stressed.

    25:52 And I see all those words, I take a nap in between there, it's too much.

    25:57 So I know reading it once is not enough for me.

    26:00 And it's really not enough for most people.

    26:03 So I want to go back and translate this NCLEX ease language that nobody speaks like.

    26:08 So for each anticipated task, okay, for each task on here, which tasks can the RN consider to be delegated to the LPN? So I can see we've got a list of tasks here, I need to see which one can be delegated to the LPN by indicating whether statement exemplifies a task within the LPN scope of practice, or is not within the LPN scope of practice.

    26:32 Ah, that makes sense.

    26:34 So on the left, we've got these tasks, right? And then we've got the column next to it, and a third column.

    26:39 The second and third column is where I'm going to click a checkbox to indicate whether it is within their scope of practice or not within their scope of practice.

    26:49 So who am I? The RN.

    26:52 Who am I talking about delegating to? The LPN.

    26:55 So I'm looking for things that are within their scope, or not within their scope.

    26:59 Okay, so first one, place a hat in the bathroom for urine collection.

    27:04 I know it sounds kind of funny if you're not a nursing student, but you guys know, we're not taking a ball cap and hanging it up in the bathroom.

    27:11 What that is, is that plastic receptacle that you put in the toilet so that the urine will drop into that and we can measure it.

    27:19 Can the LPN place a hat in the bathroom for urine collection? Absolutely.

    27:24 This is something that will assist the RN and it's not an assessment.

    27:27 They're just literally putting the plastic hat in the bathroom for urine collection.

    27:31 This is within the scope of an LPN.

    27:34 And that's the box you would check.

    27:38 All right, first one out of the way, you understand how this is going to work.

    27:41 Let's go on with the second one.

    27:43 Ask the UAP to perform the urine dipstick and finger stick blood sugar.

    27:48 Is that within LPN scope of practice? Can the LPN ask the UAP to do those? Well, is that in the UAP scope of practice? Yeah, they can do a fingerstick blood sugar, and they can do a urine dipstick.

    28:01 At the hospital, they've been trained on that it's standardized.

    28:04 Can the LPN delegate to the UAP? They sure can.

    28:09 So this would be within the LPN scope of practice, okay? And the UAP will let the LPN know what the results are.

    28:16 And the LPN will discuss with the RN.

    28:18 I know it seems like a lot of people talking to everybody, but in NCLEX world, that's how it works.

    28:24 Now the next one, assess the urine color and consistency.

    28:30 There's the a word assess the urine color and consistency.

    28:35 Is that part of the LPN scope of practice? In NCLEX world, this is only for the RN, because of the assessment that's necessary.

    28:45 So on this one, you would check, not within the scope of the LPN.

    28:50 Measure the urine output.

    28:53 Is this within the LPN scope of practice? Yeah, they can do that.

    28:57 This item, this will help the RN and it's not an assessment task.

    29:01 So I would check LPN scope of practice.

    29:04 Now, I know what you're thinking like, "My goodness, Prof Lawes, this is going to take us forever." The first time you do it, it will.

    29:13 But you see all I'm forcing myself to focus my brain every time being intentional.

    29:18 That's how you don't make silly mistakes.

    29:21 You know, the information, I just want to make sure you take credit for it.

    29:25 And a stressed brain doesn't think as clearly, so you want to make sure you take the extra safety measures to do that.

    29:32 So let's finish this out.

    29:34 Start normal saline fluid at 200 mL/h.

    29:38 Is that within the LPN scope of practice? We'll start normal saline fluid - that's an IV - at 200 mL/hour. iIs that in NCLEX world, within the LPN scope of practice? No, this should be done by the RN because it's involving an IV.

    29:57 Document the insulin start time and the client response to the insulin.

    30:02 Okay, is that within the LPN scope of practice? Well, let's go back and determine why or why not documenting insulin start time and the client response.

    30:14 Hey, insulin is a really high risk medication.

    30:18 This is something that kid, if not handled correctly, can cause severe damage to the client from a super low blood sugar.

    30:26 In fact, that's our biggest risk with insulin is hypoglycemia.

    30:31 So this type of assessment is way outside of an LPN scope of practice.

    30:37 On the NCLEX exam, remember, I told you, I know that if you're a practicing LPN, you may have already done this.

    30:44 But in NCLEX world, you have to think about their rules, not your real life practice.

    30:50 Last one, ask a UAP to obtain a blood glucose and current weight.

    30:57 Okay, so ask the UAP to obtain a blood glucose and current weight.

    31:02 Is that within the LPN scope of practice to delegate to a UAP? Yep, can they get a blood glucose? Yep, it'll have to be a fingerstick blood sugar.

    31:11 And can they get the current weight? Yes, that's totally within the practice of an LPN.

    31:18 And again, that information we pass back to the LPN and to the RN.

    31:23 Alright, so step back, look at your answers.

    31:26 You only had one of two answers.

    31:28 It is within the LPN scope of practice, or it's not unhealthy and scope of practice, read back through them one more time, and see if it makes sense to you.

    31:44 Okay, stop.

    31:45 Before you think about changing an answer, really caution yourself.

    31:49 If we went through it thoroughly the first time, you better have a really strong rationale to change your answer.

    31:55 Why am I telling you this? Because I am a chronic answer changer.

    31:59 Back when we took paper exams, I would erase my scantron so many times, by the time I handed it in, you could see through it, it was so thin.

    32:07 So answer changing can really be a dangerous thing.

    32:10 Don't check an answer till you're sure.

    32:13 And you can give rationale on why you're checking it, then when you go back, it's just to make sure one last check.

    32:19 But you should rarely have to go back and change multiple answers. Okay? Now we're at the fifth type of question in this case study.

    32:27 So when you hear people talk about these questions, hey, there are six questions and everyone.

    32:31 See, it's not quite as scary as they've tried to make it out.

    32:35 We've gone through these questions one by one, you've already done four types, or four steps in this six step case study.

    32:42 So here we are back again at what the screen is going to look like for you.

    32:46 On the left hand side, you've got the tab, the physician orders.

    32:49 On the right hand side, you've got the stem of the question and look, this time, you have three column choices.

    32:56 So one column is a task, and then you have three options.

    33:01 Is it an LPN, a UAP, or neither? Okay, so let's blow this up a little bit.

    33:07 But remember, this is what it'll look like for you on the screen.

    33:10 I see, not nearly as scary as everyone has tried to make it out to be.

    33:15 So we're gonna blow this up big.

    33:17 Let me read the question for you.

    33:19 The nurse has several tasks that are needed for this client.

    33:23 For each task below, click to specify which task is delegated to the LPN, the UAP or neither more than one choice can be selected per task.

    33:34 Okay, cool.

    33:35 This tells us a ton of information.

    33:37 So I'm the RN, I've got a whole checklist of things that need to be done.

    33:42 I either need to identify one or two, or three, but it can't be all three.

    33:50 Okay, that sounds way more confusing than even when we started.

    33:53 So let me clarify for you.

    33:56 It says click to specify which task is delegated to the LPN, the UAP, or neither.

    34:04 So when you look at the task, it could be LPN and UAP.

    34:09 It could be just the LPN or it could be not an appropriate task for either.

    34:16 Now the only way it wouldn't be an appropriate task for either would be if only the are in can do it.

    34:22 Okay, so let's work through these.

    34:24 I promise it'll start to click and make more sense as you have the opportunity to work through this.

    34:29 Okay, discuss ways to decrease blood glucose.

    34:34 Now, is that appropriate for the LPN? Well, if I'm going to discuss ways to decrease blood glucose that's going to be kind of talking about the treatment and evaluating that.

    34:45 No, that is not within a scope of practice of an LPN that is only an RN.

    34:50 So not the LPN scope, not the UAP, so I'm going to check the box neither or neither, however you would prefer to say it.

    34:59 So discussing ways to decrease the blood glucose would be more of an RN scope of practice.

    35:05 Okay, now we just get to work through the rest of the task list to answer this part of the question.

    35:11 Notify the health care provider, the HCP of the blood glucose result.

    35:17 Is that within the scope of practice for the LPN when we have an RN? No, that would be something the RN would do.

    35:26 So if it's above the scope of an LPN in NCLEX world, then it's definitely not appropriate for UAP.

    35:34 So I'm going to check neither or neither.

    35:37 Again, however you prefer to say it.

    35:40 So, so far, we've got neither, neither, or neither, neither or neither, neither.

    35:44 Whatever you got my point, you know, what we're doing.

    35:47 Third one, obtain vital signs during intravenous infusion.

    35:53 Okay, is that within the scope of practice for an LPN to get vital signs during intravenous infusion? Yeah, that'd be fine.

    36:01 An LPN couldn't get the vital signs if it was an initial assessment, but nothing in here tells me it's initial assessment.

    36:08 So don't make things up.

    36:09 Just know that, yes, that would be within an LPN scope of practice.

    36:14 Now, let's take the second column, would this be within the scope of practice of a UAP? Again, yeah, it would.

    36:23 So for this one, I'm going to check both the LPN box and the UAP box.

    36:28 Okay, now just starting to make more sense, kind of getting the hang of it feeling good, excellent.

    36:34 The next choice is assist the client with diet choices.

    36:38 Okay, so is it within the scope of practice to help the patient with diet choices? Yeah, it is.

    36:47 So you're not ordering the diet.

    36:50 The RN doesn't order the diet, the healthcare provider orders what diet the patient should be on.

    36:55 So you would just be helping the patient as an LPN, pick the choices that they want for their meals that day.

    37:01 And LPN, that's completely within their scope of practice.

    37:05 So I would check that box.

    37:07 What about UAP? Is this something that's within their scope of practice to assist the client with diet choices? Exactly, as long as they're following the diet choices that are within the ordered diet by the HCP, this is both of them.

    37:24 So I would check LPN and UAP.

    37:28 Measuring I & O, is this within LPN scope of practice? But you're probably saying, "I've never seen an LPN measure the I & O, that's always the UAP on the unit where I work." It doesn't matter.

    37:41 Is it within the scope of practice of an LPN? Is it safe for them to do that? Absolutely. So we're going to check the LPN box.

    37:49 UAP, can they measure I & O? They sure can.

    37:52 And they would report that to the RN.

    37:54 So again, we'll check both LPN and UAP.

    37:59 Next, educate the client.

    38:02 Okay, before I even go further, that word right there, educate the client on the condition that indicates a strong teaching.

    38:12 So can an LPN teach a client? No, they cannot, they can only reinforce the teaching that the RN has already done.

    38:21 So you'll see that language and the NCLEX exam, reinforce the teaching, those type of words will be used or another word that means to reinforce.

    38:29 But it will clearly indicate to you that the teaching has already been done.

    38:33 The LPN or even the UAP are just reinforcing what the nurse has taught.

    38:38 So educate the client on the condition is outside of the focus for an LPN outside of the focus for a UAP.

    38:46 So it is the neither, neither answer.

    38:49 It's not appropriate for them, because only the RN can do that.

    38:53 Now, we're at the last one.

    38:55 Obtain the next fingerstick, blood sugar or glucose.

    39:00 So is that within the scope of practice for an LPN to do a fingerstick blood sugar? Sure, is, they can do that.

    39:07 So I would check the LPN box.

    39:10 What about a UAP? Can they do a fingerstick blood glucose? Sure, it can.

    39:15 That's something that trained and checked often in the hospital.

    39:18 So you would check both LPN and UAP.

    39:21 Okay, now step back, and enjoy your work.

    39:25 Now, I want you to go back and say, "Why did I check neither on the first one?" Why did I check neither on the second one? Work through each one of these tasks, just so you feel certain about your choices? Everything look good? Well, we did this one together, and don't you wish we could do the NCLEX together.

    39:49 But they're not really intergroup projects.

    39:51 So here you go.

    39:53 This is what you would do when you're all by yourself, standing strong, taking your NCLEX exam.

    39:58 Once you feel confident that, "Yep, that represents my answers and I have explanations why." You get to go on to the last part of the case study.

    40:07 This is awesome.

    40:08 Okay, by now you know the format.

    40:11 On the left hand side, you've got the information.

    40:13 On the right hand side, you've got the part that we're going to interact with or the question.

    40:18 And on this one, we've got the three columns.

    40:21 The left side is kind of the task at first column, then you have effective delegation and ineffective delegation.

    40:28 Okay, so this kind of gives me a clue on what we're going to look at.

    40:32 I'm going to blow this up bigger for you.

    40:34 So this is what it will look like when you're taking the NCLEX.

    40:38 Let's kind of focus in on those key points.

    40:41 Here's the question, which items indicate the LPN and UAP successfully completed the assigned task? For each needed task, click to specify if the task assigned by the RN was correctly delegated by the LPN or the UAP.

    41:00 Wow, okay, that's a lot of stuff.

    41:03 So I would have to stop back up and think through this.

    41:05 So I'm looking for the items that say, successfully completed the assigned tasks for each of the needed tests.

    41:14 Click to specify if the task assigned by the RN was correctly delegated by the LPN or UAP.

    41:22 Okay, so we've got effective delegation or ineffective delegation.

    41:26 Okay, what we're looking for is, they're going to say in the left hand column, what the RN delegated.

    41:32 And you're going to check if that's appropriate for the RN to delegate that, that would be effective delegation, or if it's inappropriate for the RN to delegate it, that would be ineffective delegation.

    41:44 Let's work through them.

    41:45 So look how many we have, 1, 2, 3, 4, 5 of these.

    41:50 Obviously, we're going to start with the first one at the top.

    41:53 The LPN recorded vital signs during the IV infusion.

    41:58 Is this effective delegation or ineffective delegation? Can the LPN record vital signs during IV infusion? They can.

    42:08 So we're going to check the effective delegation box that's within their scope of practice.

    42:15 Now, what about this at the RN delegated that the UAP assisted client to make menu choices? Well, these are sounding familiar, aren't they? Right, we've just got this thing here to get you used to the types of questions that you'll have.

    42:28 So is that effective delegation for the UAP to do that? You got it.

    42:33 The UAP can assist the client with making their food choices on the menu.

    42:38 So this is an example of effective delegation or correct delegation.

    42:44 The LPN provides diabetic education on the condition.

    42:48 Is this effective delegation for the LPN to provide diabetic education? You know the answer, no, the LPN cannot do the initial teaching.

    42:58 Nothing on here indicates the LPN is reinforcing the teaching.

    43:01 So this is ineffective delegation.

    43:06 UAP measured the fluid intake and urine output.

    43:09 Is that effective delegation by the RN for the UAP to measure that? Yes, it's effective delegation.

    43:17 The UAP can measure the intake and output of a client.

    43:22 Discharged teaching provided by the LPN.

    43:25 Is that effective delegation by the RN? Okay. Do you see what we're doing every time you think like, "Why do you keep repeating what the question is?" Because what I've seen most often in students when they get a question wrong and they knew the content is that because they weren't careful about making sure they were answering the same question all the way down each of those examples, halfway through, they flip, and they start answering the reverse, so don't do that.

    43:52 That's another silly way to get a question wrong.

    43:56 So discharge teaching provided by the LPN.

    43:59 Is that correct delegation by an RN? No, it is not.

    44:04 Because an LPN cannot do initial teaching, assessments, and the teaching that's needed at discharge.

    44:11 So they can't do teaching, assessments or evaluations.

    44:15 Discharged teaching falls under special teaching, because you're sending them home to be safe.

    44:21 And that's why an LPN cannot admitted or discharged a client that's only within an RN scope of practice in NCLEX world.

    44:29 So step back, take a look at your answers.

    44:32 I want you to pause for a minute and see, "Does this make sense?" "Why did you pick each one of those answers?" Okay, that's it.

    44:47 You have wrapped up that question.

    44:49 Congratulations.

    44:51 You made it all the way through the case study in the Next-Gen format.

    44:55 You've got it.

    44:56 Just be consistent and thorough, move from left to right and you can do this.

    45:02 Join us for other videos on NCLEX questions.

    About the Lecture

    The lecture Case Study: Delegation Fund – NCLEX-RN® by Rhonda Lawes, PhD, RN is from the course Next Gen NCLEX-RN® Question Walkthrough.

    Author of lecture Case Study: Delegation Fund – NCLEX-RN®

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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