This is the full-text copy of the 100-item quiz Prioritization, Delegation, and Assignment in Nursing NCLEX Practice Questions.
Use this page to print a copy of the quiz or export it via PDF.
CREATING PDF. For most modern browsers like Chrome, Safari, Firefox, Edge, you can simply click on File> Print > Save as PDF to create a PDF version of this page.
For more quizzes, please visit Nursing Test Bank and Nursing Practice Questions for Free.
Nursing Prioritization, Delegation and Assignment NCLEX Practice Quiz #1 (25 Items)
- A. Perform postural drainage and chest physiotherapy every 4 hours.
- B. Allow the patient to decide whether she needs aerosolized medications.
- C. Place the patient in a private room to decrease the risk of further infection.
- D. Plan activities to allow at least 8 hours of uninterrupted sleep.
Correct Answer: A. Perform postural drainage and chest physiotherapy every 4 hours.
Airway clearance techniques are critical for patients with cystic fibrosis and should take priority over other activities. The Cystic Fibrosis Transmembrane Conductance Regulator defect causes mucus to become dehydrated. Secretions in cystic fibrosis are generally thick, sticky, and more difficult to clear. Frequent airway clearance is a mainstay in the treatment of acute exacerbations, as well as an integral part of health maintenance in cystic fibrosis.
- Option B: Although allowing more independent decision-making is important for adolescents, the physiologic need for an improved respiratory function takes precedence at this time. Collaborate with the client and staff to ensure that the schedule for therapy is amenable to all and does not interfere with meals, rest times, or medications.
- Option C: A private room may be desirable for the patient but is not necessary. Ensure that clients with CF are not cohorted. The cohorting of clients with CF is not recommended based on published CF Infection Control Consensus Guidelines.
- Option D: With increased shortness of breath, it will be more important that the patient has frequent respiratory treatments than 8 hours of sleep. Infection, inflammation, and mucous plugging will cause an increase in the respiratory effort to compensate for airway obstruction. As moving air into and out of the lungs becomes more difficult, the breathing pattern alters to include the use of accessory muscles and retractions.
A patient with a pulmonary embolism is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply.
- A. Use a lift sheet when moving and positioning the patient in bed.
- B. Use an electric razor when shaving the patient each day.
- C. Use a soft-bristled toothbrush or tooth sponge for oral care.
- D. Use a rectal thermometer to obtain a more accurate body temperature.
- E. Be sure the patient’s footwear has a firm sole when the patient ambulates.
Correct Answers: A, B, C, and E.
All of the other instructions are appropriate to the care of a patient receiving anticoagulants. Risk for bleeding may arise in any condition that disturbs the “close circuit” integrity of the circulatory system. Bleeding is the primary complication of anticoagulant therapy and is a risk of all anticoagulants even when maintained within the usual therapeutic ranges.
- Option A: Educate the at-risk patient about precautionary measures to prevent tissue trauma or disruption of the normal clotting mechanisms. Information about precautionary measures lessens the risk for bleeding.
- Option B: Be careful when using sharp objects like scissors and knives. Use an electric razor for shaving (not razor blades). The patient needs to avoid situations that may cause tissue trauma and increase the risk for bleeding.
- Option C: Use a soft-bristled toothbrush and nonabrasive toothpaste. Avoid the use of toothpicks and dental floss. This method providing oral hygiene reduces trauma to oral mucous membranes and the risk for bleeding from the gums.
- Option D: While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). These invasive devices or medications may cause trauma to the mucous membranes that line the rectum or vagina.
- Option E: Educate the patient and family members about signs of bleeding that need to be reported to a health care provider. Early evaluation and treatment of bleeding by a health care provider reduces the risk for complications from blood loss.
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a non-rebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient’s care, you would anticipate a physician order for what action?
- A. Perform endotracheal intubation and initiate mechanical ventilation.
- B. Immediately begin continuous positive airway pressure (CPAP) via the patient’s nose and mouth.
- C. Administer furosemide (Lasix) 100 mg IV push stat.
- D. Call a code for respiratory arrest.
Correct Answer: A. Perform endotracheal intubation and initiate mechanical ventilation
A non-rebreather mask can deliver nearly 100% oxygen. When the patient’s oxygenation status does not improve adequately in response to the delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually, at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless healthcare care providers intervene by providing intubation and mechanical ventilation to decrease the patient’s work of breathing.
- Option B: To maintain oxygenation, ARDSnet recognizes the benefit of PEEP. The protocol allows for a low or a high PEEP strategy relative to FiO2. Either strategy tolerates a PEEP of up to 24 cm HO in patients requiring 100% FiO2. Interestingly, the mode in which a patient is ventilated affects lung recovery. Evidence suggests that some ventilatory strategies can exacerbate alveolar damage and perpetuate lung injury in the context of ARDS.
- Option C: The chief treatment strategy is supportive care and focuses on 1) reducing shunt fraction, 2) increasing oxygen delivery, 3) decreasing oxygen consumption, and 4) avoiding further injury. Patients are mechanically ventilated, guarded against fluid overload with diuretics, and given nutritional support until evidence of improvement is observed.
- Option D: The major cause of death in patients with ARDS was sepsis or multiorgan failure. While mortality rates are now around 9% to 20%, it is much higher in older patients. ARDS has significant morbidity as these patients remain in the hospital for extended periods and have significant weight loss, poor muscle function, and functional impairment.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant?
- A. Assisting the patient to sit up on the side of the bed.
- B. Instructing the patient to cough effectively.
- C. Teaching the patient to use incentive spirometry.
- D. Auscultation of breath sounds every 4 hours.
Correct Answer: A. Assisting the patient to sit up on the side of the bed.
Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of a nursing assistant. Some examples of tasks and aspects of care that can be delegated legally to nonprofessional, unlicensed assistive nursing personnel, provided they are competent in these areas, under the direct supervision of the nurse include assistance with transfers, range of motion, feeding, ambulation, and other tasks such as making beds and assisting with bowel and bladder functions.
- Option B: The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for.
- Option C: Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate for a licensed nurse. Based on the basic entry educational preparation differences among these members of the nursing team, care should be assigned according to the level of education of the particular team member.
- Option D: Among the tasks that cannot be legally and appropriately delegated to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides, include assessments, nursing diagnosis, establishing expected outcomes, evaluating care and any and all other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment, and professional knowledge.
A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant?
- A. Discuss weight-loss strategies such as diet and exercise with the patient.
- B. Teach the patient how to set up the BiPAP machine before sleeping.
- C. Remind the patient to sleep on his side instead of his back.
- D. Administer modafinil (Provigil) to promote daytime wakefulness.
Correct Answer: C. Remind the patient to sleep on his side instead of his back.
The nursing assistant can remind patients about actions that have already been taught by the nurse and are part of the patient’s plan of care. The right person must be assigned to the right tasks and jobs under the right circumstances. The nurse who assigns the tasks and jobs must then communicate with and direct the person doing the task or job. The nurse supervises the person and determines whether or not the job was done in the correct, appropriate, safe, and competent manner.
- Option A: Among the tasks that cannot be legally and appropriately delegated to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides, include assessments, nursing diagnosis, establishing expected outcomes, evaluating care, and any and all other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment, and professional knowledge.
- Option B: The registered nurse must also ensure that the delegated tasks are permissible according to the nursing team members’ position description which is also referred to as the job description, and the particular facility’s specific policies and procedures relating to client care and who can and who cannot perform certain tasks.
- Option D: Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can delegate the administration of medication to an LPN/LVN.
After a change of shift, you are assigned to care for the following patients. Which patient should you assess first?
- A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab.
- B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation.
- C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics.
- D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator.
Correct Answer: D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator.
The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient’s needs are urgent. In particular, a patient who is chronically on short-acting beta-2 agonists risks not achieving the same relief from their medicine as they once did. This phenomenon is called receptor downregulation. It happens because a portion of the receptors targeted end up being inactivated by the body due to overuse.
- Option A: The sterile sputum specimen of the patient should be sent to the laboratory for not more than 60 minutes, or it will not be acceptable. This is not an urgent case and can be done after the nurse sees the other patients.
- Option B: In COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable. In the treatment of exacerbations of chronic obstructive pulmonary disease (COPD), oxygen should be titrated to achieve a target oxygen saturation range of 88–92%. This results in a greater than twofold reduction in mortality, compared with the routine administration of high-concentration oxygen therapy
- Option C: The other patients need to be assessed as soon as possible, but none of their situations are urgent. Patients older than 60 years or younger than 4 years of age have a relatively poorer prognosis than young adults. If pneumonia is left untreated, the overall mortality may become 30%. The Pneumonia Severity Index (PSI) may be utilized as a tool to establish a patient’s risk of mortality.
After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the registered nurse immediately?
- A. Heart rate of 98 beats/min
- B. Respiratory rate of 24 breaths/min
- C. Blood pressure of 168/90 mm Hg
- D. Tympanic temperature of 101.4ºF (38.6ºC)
Correct Answer: D. Tympanic temperature of 101.4ºF (38.6ºC)
Infections are always a threat to the patient receiving mechanical ventilation. The endotracheal tube bypasses the body’s normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the respiratory system.
- Option A: The normal range used in an adult is between 60 to 100 beats/minute with rates above 100 beats/minute and rates below 60 beats per minute, referred to as tachycardia and bradycardia, respectively. The rate of the pulse is significant to measure for assessing the physiological and pathological processes affecting the body.
- Option B: The normal breathing rate is about 12 to 20 breaths per minute in an average adult. Tachypnea is described as a respiratory rate of more than 20 breaths per minute that could occur in physiological conditions like exercise, emotional changes, or pregnancy. Pathological conditions like pain, pneumonia, pulmonary embolism, asthma, foreign body aspiration, anxiety conditions, sepsis, carbon monoxide poisoning, and diabetic ketoacidosis can also present with tachypnea.
- Option C: Blood pressure is an essential vital sign to comprehend the hemodynamic condition of the patient. Unfortunately, though, there are a lot of inter-person variabilities when measuring it. All healthcare providers should be aware of making sure all the essential prerequisites are met before checking the blood pressure of the patient.
An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply.
- A. Auscultate breath sounds
- B. Administer medications via metered-dose inhaler (MDI)
- C. Complete in-depth admission assessment
- D. Initiate the nursing care plan
- E. Evaluate the patient’s technique for using MDI’s
Correct Answers: A and B.
Appropriate decisions relating to the successful assignment of care are accurately based on the needs of the patient, the skills of the staff, the staffs’ position description or job descriptions, the employing facility’s policies and procedures, and legal aspects of care such as the states’ legal scopes of practice for nurses, nursing assistants and other members of the nursing team.
- Option A: The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. The scope of practice for the licensed practical or vocational nurse will most likely include the legal ability of this nurse to perform data collection, plan, implement, and evaluate care under the direct supervision and guidance of the registered nurse.
- Option B: Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN. Based on the basic entry educational preparation differences among these members of the nursing team, care should be assigned according to the level of education of the particular team member.
- Option C: Scopes of practice should be considered prior to the assignment of care. All states have scopes of practice for advanced nurse practitioners, registered nurses, licensed practical nurses and unlicensed assistive personnel like nursing assistants and patient care technicians.
- Option D: The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for. Some staff members may possess greater expertise than others.
- Option E: Independently completing the admission assessment, initiating the nursing care plan, and evaluating a patient’s abilities require additional education and skills. These actions are within the scope of practice of the professional RN.
The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit?
- A. A 58-year old on airborne precautions for tuberculosis (TB).
- B. A 68-year old just returned from a bronchoscopy and biopsy.
- C. A 72-year old who needs teaching about the use of incentive spirometry.
- D. A 69-year old with COPD who is ventilator dependent.
Correct Answer: C. A 72-year old who needs teaching about the use of incentive spirometry
Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care.
- Option A: To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. All healthcare facilities and agencies must assess and validate competency before total care or any aspect of care is performed by an individual without the direct supervision of another, regardless of their years of experience.
- Option B: The bronchoscopy patient needs a specialized procedure. The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for.
- Option D: The ventilator-dependent patient needs a nurse who is familiar with ventilator care. Some patients require high levels of professional judgment and skill; and other patient needs are somewhat routine and without the need for high levels of professional judgment and skill.
The high-pressure alarm on a patient’s ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next?
- A. Reassure the patient that the ventilator will do the work of breathing for him.
- B. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm.
- C. Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning.
- D. Insert an oral airway to prevent the patient from biting on the endotracheal tube.
Correct Answer: B. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm
Manual ventilation of the patient will allow you to deliver a FiO2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. Proper ventilation techniques with the BVM should consider safe ventilation parameters for each individual patient and their conditions.
- Option A: The patient may need reassurance, but this is not the priority nursing intervention. Indicators of appropriate ventilation include but are not limited to patient chest rise, skin color, electronic vital sign monitoring, resistance on bag squeeze according to patient lung pathology, CO2 monitoring, and a flashing light on the BVM for rate of breath delivery.
- Option C: Excessive volume, pressure or flow may result in morbidity from lung damage, stomach insufflation, or hemodynamic and pulmonary compromise. Lower tidal volumes are needed in ARDS to prevent regional overdistension.
- Option D: The patient may need insertion of an oral airway, but the first step should be an assessment of the reason for the high-pressure alarm and resolution of the hypoxemia. PEEP (5–20 cmH2O) is a key element of protective ventilation and is routinely applied in all patients with ARDS to facilitate adequate oxygenation and maintain alveolar recruitment.
The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient’s comfort for this problem?
- A. Suggest that the patient’s oxygen be humidified.
- B. Suggest that a simple face mask be used instead of a nasal cannula.
- C. Suggest that the patient be provided with an extra pillow.
- D. Suggest that the patient sit up in a chair at the bedside.
Correct Answer: A. Suggest that the patient’s oxygen be humidified.
When the oxygen flow rate is higher than 4 L/min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. It is reasonable to use humidified oxygen for patients who require high-flow oxygen systems for more than 24 hours or who report upper airway discomfort due to dryness. Application of a water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.
- Option B: For patients wearing a nasal cannula for standard oxygen supplementation, switching to high-flow nasal cannula oxygen therapy (HNFC) may be a good alternative to combat the side effect of dry nose.
- Option C: Providing an extra pillow would not alleviate the dryness of the patient’s nose. Water-based lubricants, such as K-Y jelly, help prevent dryness, irritation, and cracking of the nose commonly associated with supplemental oxygen therapy, BiPAP, and CPAP by adding moisture to the affected area.
- Option D: Changing the patient’s position would not treat the dry nose. Medical oxygen contains no moisture, so regular or even occasional use can dry out the nasal passages. Nasal saline spray adds moisture to dry nasal passages and assists the nose’s natural cleaning system. It’s important to keep the nasal passages moist because bacterial infections can develop under the nasal crusts that develop inside dry nostrils.
When a patient with TB is being prepared for discharge, which statement by the patient indicates the need for further teaching?
- A. “Everyone in my family needs to go and see the doctor for TB testing.”
- B. “I will continue to take my isoniazid until I am feeling completely well.”
- C. “I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag.”
- D. “I will change my diet to include more foods rich in iron, protein, and vitamin C.”
Correct Answer: B. “I will continue to take my isoniazid until I am feeling completely well.”
Patients taking isoniazid must continue the drug for 6 months. The other 3 statements are accurate and indicate an understanding of TB. Drug of choice is isoniazid. It is usually given with vitamin B6, pyridoxine (to prevent nerve damage). Isoniazid is recommended for Mantoux or quantiferon positive individuals and should be continued for 6 or 9 months.
- Option A: Family members should be tested because of their repeated exposure to the patient. Most people who develop tuberculosis do so after a long period of latency (usually several years after initial primary infection). This is known as secondary tuberculosis.
- Option C: Covering the nose and mouth when sneezing or coughing, and placing the tissues in plastic bags help prevent transmission of the causative organism. Although usually a lung infection, tuberculosis is a multi-system disease with protean manifestation. The principal mode of spread is through inhalation of infected aerosolized droplets.
- Option D: The dietary changes are recommended for patients with TB. Nutritional supplementation may help to improve outcomes in tuberculosis patients. A study found that nutritional counseling to increase energy intake combined with provision of supplements, when started during the initial phase of tuberculosis treatment, produced a significant increase in body weight, total lean mass, and physical function after six weeks.
To improve respiratory status, which medication should you be prepared to administer to the newborn infant with respiratory distress syndrome (RDS)?
- A. Theophylline (Theolair, Theochron)
- B. Surfactant (Exosurf)
- C. Dexamethasone (Decadron)
- D. Albuterol (Proventil)
Answer: B. Surfactant (Exosurf)
Exosurf neonatal is a form of synthetic surfactant. An infant with RDS may be given two to four doses during the first 24 to 48 hours after birth. It improves respiratory status, and research has shown a significant decrease in the incidence of pneumothorax when it is administered.
- Option A: Theophylline is indicated for the treatment of asthma and COPD (bronchitis, emphysema). Theophylline relaxes the smooth muscles located in the bronchial airways and pulmonary blood vessels. It also reduces the airway responsiveness to histamine, adenosine, methacholine, and allergens.
- Option C: Dexamethasone has a wide variety of uses in the medical field. As a treatment, dexamethasone has been useful in the treatment of acute exacerbation of multiple sclerosis, allergies, cerebral edema, inflammation, and shock. It works by suppressing the migration of neutrophils and decreasing lymphocyte colony proliferation.
- Option D: Albuterol is often used for the treatment of pediatric acute asthma. Albuterol acts on beta-2 adrenergic receptors to relax the bronchial smooth muscle. It also inhibits the release of immediate hypersensitivity mediators from cells, especially mast cells.
The clinical instructor directed the student nurse to care for a client whose potassium is 6.7 mEq/L. Which intervention is delegated correctly to the student nurse?
- A. Give potassium 10 mEq orally
- B. Give sodium polystyrene sulfonate (Kayexalate) 15 g orally
- C. Give spironolactone (Aldactone) 25 mg orally
- D. Assess electrocardiogram (ECG) strip for tall T waves
Correct Answer: B. Give sodium polystyrene sulfonate (Kayexalate) 15 g orally
Delegation, supervision. The normal range for potassium is 3.5 to 5 mEq/L. The client’s potassium level is high. Kayexalate eliminates potassium from the body through the gastrointestinal system. The right person must be assigned to the right tasks and jobs under the right circumstances. The nurse who assigns the tasks and jobs must then communicate with and direct the person doing the task or job.
- Option A: Giving additional potassium may further increase the serum potassium level. The registered nurse determines and analyzes all of the health care needs for a group of clients; the registered nurse delegates care that matches the skills of the person that the nurse is delegating to.
- Option C: Spironolactone is a potassium-sparing diuretic that may cause the client’s potassium level to go even higher. The delegating registered nurse remains accountable for all client care despite the fact that some of these aspects of care can, and are, delegated to others.
- Option D: The beginning nursing student does not have the skill to assess ECG strips. Some client needs are relatively predictable; and other patient needs are unpredictable based on the changing status of the client. Some needs require high levels of professional judgment and skill; and other patient needs are somewhat routine and without the need for high levels of professional judgment and skill.
The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision?
- A. Observe how well the patient performs pursed-lip breathing.
- B. Plan a nursing care regimen that gradually increases activity intolerance.
- C. Assist the patient with basic activities of daily living.
- D. Consult with the physical therapy department about reconditioning exercises.
Correct Answer: A. Observe how well the patient performs pursed-lip breathing
Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. The scope of practice for the licensed practical or vocational nurse will most likely include the legal ability of this nurse to perform data collection, plan, implement and evaluate care under the direct supervision and guidance of the registered nurse.
- Option B: Planning requires additional education and skills, appropriate to an RN. The scope of practice for the registered nurse will most likely include the legal ability of the registered professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis, planning, implementation and evaluation.
- Option C: Assisting patients with ADLs is more appropriately delegated to a nursing assistant. Some examples of tasks and aspects of care that can be delegated legally to nonprofessional, unlicensed assistive nursing personnel, provided they are competent in these areas, under the direct supervision of the nurse include assisting the client with their activities of daily living such as ambulation, dressing, grooming, bathing and hygiene.
- Option D: Scopes of practice are also considered prior to the assignment of care. All states have scopes of practice for advanced nurse practitioners, registered nurses, licensed practical nurses and unlicensed assistive personnel like nursing assistants and patient care technicians.
When assessing a 22-year old patient who required emergency surgery and multiple transfusions 3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate?
- A. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes.
- B. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs.
- C. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation.
- D. Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status.
Correct Answer: D. Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status.
The patient’s history and symptoms suggest the development of ARDS, which will require intubation and mechanical ventilation. Patients are mechanically ventilated, guarded against fluid overload with diuretics, and given nutritional support until evidence of improvement is observed.
- Option A: The maximum oxygen delivery with a nasal cannula is a Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Interestingly, the mode in which a patient is ventilated affects lung recovery. Evidence suggests that some ventilatory strategies can exacerbate alveolar damage and perpetuate lung injury in the context of ARDS.
- Option B: Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. The chief treatment strategy is supportive care and focuses on 1) reducing shunt fraction, 2) increasing oxygen delivery, 3) decreasing oxygen consumption, and 4) avoiding further injury.
- Option C: Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia. A lung-protective ventilatory strategy is advocated to reduce lung injury. Novel invasive ventilation strategies have been developed to improve oxygenation. These include airway pressure release ventilation (APRV) and high-frequency oscillation ventilation (children).
Which of these medication orders for a patient with a pulmonary embolism is more important to clarify with the prescribing physician before administration?
- A. Warfarin (Coumadin) 1.0 mg by mouth (PO)
- B. Morphine sulfate 2 to 4 mg IV
- C. Cephalexin (Keflex) 250 mg PO
- D. Heparin infusion at 900 units/hr
Correct Answer: A. Warfarin (Coumadin) 1.0 mg by mouth (PO)
Medication safety guidelines indicate that the use of a trailing zero is not appropriate when writing medication orders because the order can easily be mistaken for a larger dose, such as 10 mg. The order should be clarified before administration. The other orders are appropriate, based on the patient’s diagnosis.
- Option B: FDA-approved usage of morphine sulfate includes moderate to severe pain that may be acute or chronic. Most commonly used in pain management, morphine provides major relief to patients afflicted with pain.
- Option C: Cephalexin is an FDA-approved antibiotic. Cephalexin is a first-generation cephalosporin utilized in the treatment of urinary tract infections, respiratory infections, and other bacterial infections. Cephalexin is also commonly used in treating streptococcal and staphylococcal skin infections.
- Option D: Unfractionated heparin is an anticoagulant indicated for both the prevention and treatment of thrombotic events such as deep vein thrombosis (DVT) and pulmonary embolism (PE) as well as atrial fibrillation (AF). Heparin is also used to prevent excess coagulation during procedures such as cardiac surgery, extracorporeal circulation, or dialysis, including continuous renal replacement therapy.
You are a team leader RN working with a student nurse. The student nurse is to teach a patient how to use an MDI without a spacer. Put in the correct order the steps that the student nurse should teach the patient.
- 1. Remove the inhaler cap and shake the inhaler
- 2. Tilt your head back and breathe out fully
- 3. Open your mouth and place the mouthpiece 1 to 2 inches away
- 4. Press down firmly on the canister and breathe deeply through your mouth
- 5. Hold your breath for at least 10 seconds
- 6. Wait at least 1 minute between puffs
The correct order is shown above.
- Before each use, the cap is removed and the inhaler is shaken according to the instructions in the package insert.
- Next, the patient should tilt the head back and breathe out completely.
- Each inhaler consists of a small canister of medicine connected to a mouthpiece. The canister is pressurized. As the patient presses down on the inhaler, it releases a mist of medicine.
- As the patient begins to breathe deeply through the mouth, the canister should be pressed down to release one puff (dose) of the medication.
- The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs.
- The patient should wait for at least 1 minute between puffs from the inhaler.
You are acting as a preceptor for a newly graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide care to which patients? Select all that apply.
- A. A 38-year old with moderate persistent asthma awaiting discharge.
- B. A 63-year old with a tracheostomy needing tracheostomy care every shift.
- C. A 56-year old with lung cancer who has just undergone left lower lobectomy.
- D. A 49-year old just admitted with a new diagnosis of esophageal cancer.
Correct Answer: A and B.
- Option A: A patient who is waiting for discharge may be stable enough for the care of the student nurse. The client is the center of care. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs.
- Option B: The new RN is at an early point in her orientation. The most appropriate patients to assign to her are those in stable condition who require routine care. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the policies and procedures within the particular healthcare facility.
- Option C: The patient with the lobectomy will require the care of a more experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. Some needs require high levels of professional judgment and skill; and other patient needs are somewhat routine and without the need for high levels of professional judgment and skill.
- Option D: The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. As the new nurse advances through her orientation, you will want to work with her in providing care for these patients with more complex needs.
Jenna is a nurse from the medical-surgical unit of a tertiary hospital. She was asked to float on the orthopedic ward in which she has no prior experience working on. Which client should be assigned to her?
- A. A client with a cast for a fractured femur and who has numbness and discoloration of the toes.
- B. A client with balanced skeletal traction and needs assistance with morning care.
- C. A client who had an above-the-knee amputation yesterday and currently has a temperature of 101.4ºF.
- D. A client who had a total hip replacement two days ago and needs blood glucose monitoring.
Correct Answer: D. A client who had a total hip replacement two days ago and needs blood glucose monitoring.
A nurse from the medical-surgical floor floated to the orthopedic unit should be given clients with a stable condition as those who have care similar to her training and experience. A client who is in a postoperative state is more likely to be in a stable condition.
- Option A: The client may be experiencing compartment syndrome and would need the expertise of an orthopedic nurse. Acute compartment syndrome is a condition in which there is increased pressure within a closed osteofascial compartment, resulting in impaired local circulation. Without prompt treatment, acute compartment syndrome can lead to ischemia and eventually, necrosis.
- Option B: The care of a patient with skeletal traction would need a nurse who had experience with handling the apparatus. It requires frequent reassessment of neurovascular function of the extremity after application of the traction.
- Option C: A newly recovered postoperative patient should be monitored by an experienced ortho nurse. An above-knee amputation is associated with enormous morbidity; unlike a below-knee amputation, fitting a prosthesis for an above-knee stump is difficult.
Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team?
- A. Evaluating the patient’s complaint of chest pain.
- B. Monitoring laboratory values for changes in oxygenation.
- C. Assessing for symptoms of respiratory failure.
- D. Auscultating the lungs for crackles.
Correct Answer: D. Auscultating the lungs for crackles.
An LPN who has been trained to auscultate lung sounds can gather data by routine assessment and observation, under the supervision of an RN. The scope of practice for the licensed practical or vocational nurse will most likely include the legal ability of this nurse to perform data collection, plan, implement and evaluate care under the direct supervision and guidance of the registered nurse.
- Option A: The scope of practice for the registered nurse will most likely include the legal ability of the registered professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis, planning, implementation and evaluation.
- Option B: Part of supervision entails the ongoing evaluation of staff’s ability by the registered nurse to perform assigned tasks using direct observations and with indirect observations of patient safety, the quality of the care provided, the appropriateness of care provided, and the timeliness of care provided.
- Option C: Independently evaluating patients, assessing for symptoms of respiratory failure, and monitoring and interpreting laboratory values require additional education and skill, appropriate to the scope of practice of the RN.
The nurse plans to care for a client in the post-anesthesia care unit. Which of the following should the nurse assess first?
- A. Respiratory status
- B. Level of consciousness
- C. Level of pain
- D. Reflexes and movement of extremities
Correct Answer: A. Respiratory status
Assessing respiratory status is the first priority. Remember ABC. General anesthesia and mechanical ventilation impair pulmonary function, even in normal individuals, and result in decreased oxygenation in the postanesthesia period. They also cause a reduction in functional residual capacity of up to 50% of the preanesthesia value.
- Option B: A level of consciousness assessment is also helpful, such as the AVPU scale or the Glasgow Coma Scale. The AVPU scale assesses if the patient is alert and oriented, responds to voice, responds to pain, or is unresponsive. The Glasgow Coma Scale is an objective way to record the conscious state of a patient, examining eye, verbal, and motor responses.
- Option C: Pain is a common occurrence after most all types of surgical procedures and is probably the most significant postoperative problem in the eyes of the patient. Prompt and adequate pain relief is a critical nursing intervention.
- Option D: Neurologic functions can be assessed by the patient’s response to verbal stimuli, pupils’ responsiveness to light and accommodation, ability to move all extremities, and strength and equality of a hand grip.
Nurse Jackie is reviewing the diet of a 28-year-old female who reports several months of intermittent abdominal pain, abdominal bloating, and flatulence. The nurse should tell the client to avoid:
- A. Fiber
- B. Broccoli
- C. Yogurt
- D. Simple carbohydrates
Correct Answer: B. Broccoli
Broccoli is known to be gas-forming which can lead to bloating and therefore, should be avoided. In general, gassy foods are those that contain certain sugars (fructose, lactose, raffinose, and sorbitol) and/or soluble fiber. These substances are not digested at the level of the stomach and thus make their way down to the intestines where bacteria break them down. The end result of this breakdown is the release of gas.
- Option A: One way to prevent uncomfortable intestinal gas is to slowly increase the fiber in the diet. Giving the body a chance to get used to processing the increase in fiber will make the transition easier and reduce the amount of intestinal gas to deal with.
- Option C: Plain yogurt can actually help the stomach because it contains probiotics, which are known to regulate digestion. However, if the patient is eating flavored yogurt that’s high in sugar, she’ll have more fermentation going on in her body, which means more gas and bloating.
- Option D: Complex Carbohydrate Intolerance (CCI) occurs because there is a lack of the enzyme necessary to digest complex carbohydrates. There is little gas production in the small intestine because the bacterial concentration is low. When the undigested carbohydrates reach the colon, the bacteria that normally live in the colon ferment them. This fermentation often results in the production of gas.
Nurse Jenny of Nurseslabs Medical Center is planning care for a client who had undergone colposcopy. Which of the following actions should the RN take first?
- A. Discuss the client’s fear regarding potential cervical cancer.
- B. Assist with silver nitrate application to the cervix to control bleeding.
- C. Give instructions regarding douching and sexual relations.
- D. Administer pain medications.
Correct Answer: B. Assist with silver nitrate application to the cervix to control bleeding.
Colposcopy is a procedure to examine the cervix, vagina, and vulva for signs of disease. The priority nursing action when caring for a client who underwent colposcopy is to assist in controlling potential bleeding by applying silver nitrate to the cervix.
- Option A: Colposcopy is a procedure in which a lighted, magnifying instrument called a colposcope is used to examine the cervix, vagina, and vulva. The indications for a colposcopy to be performed are risk-based. Women referred for colposcopy have a variety of underlying risks for cervical pre-cancer based on their cytological results, the HPV testing if it was performed, and personal history of cervical dysplasia.
- Option C: There is no required preparation for the patient having the colposcopy; however, it can be difficult to perform if she is on her menstrual cycle due to obscuring blood. Having the room with the proper equipment readily available will expedite the patient’s visit.
- Option D: The procedure is typically not painful. It does not require local or regional anesthesia. Slight discomfort may be felt when a speculum is inserted into the vagina, which can be minimized by deep breathing during the procedure.
Sally is a nurse working in an emergency department and receives a client after a radiological accident. Which task is the utmost priority for the nurse to do first?
- A. Decontaminate the client’s clothing.
- B. Decontaminate the open wound on the client’s thigh.
- C. Decontaminate the examination room the client is placed in.
- D. Save the client’s vomitus for analysis by the radiation safety staff.
Correct Answer: B. Decontaminate the open wound on the client’s thigh.
Decontaminating an open wound is the first priority for the client. This minimizes the absorption of radiation in the client’s body. A radiological accident is an event that involves the release of potentially dangerous radioactive materials into the environment. This release is usually in the form of a cloud or “plume” and could affect the health and safety of anyone in its path.
- Option A: Getting radioactive material off the body as soon as possible can lower a worker’s radiation dose from external contamination. Removing outer clothing and showering or, at a minimum, washing the face, hands, and any other exposed skin are essential decontamination steps.
- Option C: Decontamination of emergency response workers, their clothing, and any equipment, including PPE they may be using, is essential to limit radiation dose and prevent the spread of radioactive contamination outside of the response area.
- Option D: A prodromal period during which victims may experience loss of appetite, nausea, vomiting, fatigue, and diarrhea; after extremely high doses, additional symptoms such as fever, prostration (laying down), respiratory distress, and hyper-excitability can occur. In cases where the dose is not sufficient to cause rapid death, these symptoms usually disappear within 1-2 days.