You can delegate authority, but you cannot delegate responsibility.
Included topics in this exam are:
- Delegation and Assignment
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Nursing Prioritization, Delegation and Assignment 3 (15 Items)
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Nursing Prioritization, Delegation and Assignment 3 (15 Items)
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1. You are admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient’s history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus?
A. The patient was recently in a motor vehicle accident
B. The patient participated in an aerobic exercise program for 6 months
C. The patient gave birth to her youngest child 1 year ago
D. The patient was on bed rest for 6 hours after a diagnostic procedure
2. You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced nursing assistant?
A. Assessing the patient’s respiratory status every 4 hours
B. Taking vital signs and pulse oximetry readings every 4 hours
C. Checking the ventilator settings to make sure they are as prescribed
D. Observing whether the patient’s tube needs suctioning every 2 hours
3. You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care?
A. Administer ordered antibiotics as scheduled
B. Hyperoxygenate the patient before suctioning
C. Maintain the head of the bed at a 30 – to 45-degree angle
D. Suction the airway when coarse crackles are audible
4. You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you immediately?
A. The patient has fine bibasilar crackles
B. The patient’s respiratory rate is 8 breaths/min.
C. The patient sits up and leans over the night table.
D. The patient has a large barrel chest.
A. Teaching the patient about the importance of adequate of fluid intake and hydration.
B. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed
C. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake
D. Encouraging the patient to take a deep breath, hold it for 2 seconds, then cough two or three times in succession.
6. You are making a home visit to a 50-year old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism. The patient’s only medication is enoxaparin (Lovenox) subcutaneously. Which assessment information will you need to communicate to the physician?
A. The patient says that her right leg aches all night
B. The right calf is warm to the touch and is larger than the left calf
C. The patient is unable to remember her husband’s first name
D. There are multiple ecchymotic areas on the patient’s arms
7. You are providing care for a patient with recently diagnosed asthma. Which key points would you be sure to include in your teaching plan for this patient? (Select all that apply)
A. Avoid potential environmental asthma triggers such as smoke
B. Use the inhaler 30 minutes before exercising to prevent bronchospasm
C. Wash all bedding in cold water to reduce and destroy dust mites.
D. Be sure to get at least 8 hours of rest and sleep every night.
E. Avoid foods prepared with monosodium glutamate (MSG)
A. Pulmonary embolus
9. You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given a nursing diagnosis of Activity Intolerance. Which action should you delegate to the nursing assistant?
A. Instructing the patient to alternate rest and activity periods
B. Encouraging, monitoring, and recording nutritional intake
C. Monitoring cardiorespiratory response to activity
D. Planning activities for periods when the patient has the most energy
10. You are supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would you clearly instruct the nursing student to notify you about immediately?
A. Chest tube drainage of 10 to 15 mL/hr
B. Continuous bubbling in the water seal chamber
C. Complaints of pain at the chest tube site
D. Chest tube dressing dated yesterday
A. Suctioning the tracheostomy tube before performing tracheostomy care
B. Removing old dressings and cleaning off excess secretions
C. Removing the inner cannula and cleaning using universal precautions
D. Replacing the inner cannula and cleaning the stoma site.
E. Changing the soiled tracheostomy ties and securing the tube in place
12. You are supervising an RN who was pulled from the medical-surgical floor to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which of these directions would you clearly proved to the RN? (Select all that apply)
A. Position the patient supine and turned on his side
B. Apply direct lateral pressure to the nose for 5 minutes
C. Maintain universal body substances precautions.
D. Apply ice or cool compresses to the nose
E. Instruct the patient not to blow the nose for several hours.
13. You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately?
A. Assessing for bilateral breath sounds and symmetrical chest movements
B. Auscultating over the stomach to rule out esophageal intubation
C. Marking the tube 1 cm from where it touches the incisor tooth or nares
D. Ordering a chest radiograph to verify that tube placement is correct
14. You have just finished assisting the physician with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is important to report to the physician?
A. The patient starts crying and says she can’t go on with treatment much longer
B. The patient complains of sharp, stabbing chest pain with every deep breath
C. The patient’s blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min
D. The patient’s dressing at the thoracentesis site has 1 cm of bloody drainage
15. You have obtained the following assessment information about a 3-year old who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow-up?
A. Frequent swallowing
B. Hypotonic bowel sounds
C. Complaints of a sore throat
D. Heart rate of 112 beats/min
Answers and Rationale
1. Answer: A. The patient was recently in a motor vehicle accident
Rationale: Patients who have recently experienced trauma are at risk for deep vein thrombosis and pulmonary embolus. None of the other findings are risk factors for pulmonary embolus. Prolonged immobilization is also a risk factor for DVT and pulmonary embolus, but this period of bed rest was very short.
2. Answer: B. Taking vital signs and pulse oximetry readings every 4 hours
Rationale: The nursing assistant’s educational preparation includes measurement of vital signs, and an experienced nursing assistant would know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN
3. Answer: C. Maintain the head of the bed at a 30 – to 45-degree angle
Rationale: Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP
4. Answer: B. The patient’s respiratory rate is 8 breaths/min.
Rationale: For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This patient’s oxygen flow is too high and is causing a high serum oxygen level, which results in a decreased respiratory arrest. Crackles, barrel chest, and assumption of a sitting position leaning over the night table are common in patients with chronic emphysema
5. Answer: C. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake
Rationale: A nursing assistant can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic nursing assistant. However, an experienced nursing assistant could assist the patient with positioning after the nursing assistant and the patient had been taught the proper technique. The nursing assistant would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill, and is within the scope of practice of the RN
6. Answer: C. The patient is unable to remember her husband’s first name
Rationale: Confusion in a patient this age is unusual and may be an indication of intracerebral bleeding associated with enoxaparin use. The right leg symptoms are consistent with a resolving deep vein thrombosis; the patient may need teaching about keeping the right leg elevated above the heart to reduce swelling and pain. The presence of ecchymoses may point to a need to do more patient teaching about avoiding injury while taking anticoagulants but does not indicate that the physician needs to be called.
7. Answer: A, B, D, and E.
Rationale: Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma.
8. Answer: C. Pneumothorax
Rationale: The most common complications after birth for infants with RDS is pneumothorax. Alveoli rupture and air leaks into the chest and compresses the lungs, which makes breathing difficult
9. Answer: B. Encouraging, monitoring, and recording nutritional intake
Rationale: The nursing assistant’s training includes how to monitor and record intake and output. After the nurse has taught the patient about the importance of adequate nutritional intake for energy, the nursing assistant can remind and encourage the patient to take in adequate nutrition. Instructing patients and planning activities require more education and skill, and are appropriate to the RN’s scope of practice. Monitoring the patient’s cardiovascular response to activity is a complex process requiring additional education, training, and skill, and falls within the RN’s scope of practice
10. Answer: B. Continuous bubbling in the water seal chamber
Rationale: Continuous bubbling indicates an air leak that must be identified. With the physician’s order you can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion, which will require you to notify the physician. If the air bubbling does not stop when you apply the padded clamp, the air leak is between the clamp and the drainage system, and you must assess the system carefully to locate the leak. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. The patient’s complaints of pain need to be assessed and treated. This is important but is not as urgent as investigating a chest tube leak.
11. Answer: C. Removing the inner cannula and cleaning using universal precautions
Rationale: When tracheostomy care is performed, a sterile field is set up and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate.
12. Answers: B, C, D, and E.
Rationale: The correct position for a patient with an anterior nosebleed is upright and leaning forward to prevent blood from entering the stomach and avoid aspiration. All of the other instructions are appropriate according to best practice for emergency care of a patient with an anterior nosebleed
13. Answer: C. Marking the tube 1 cm from where it touches the incisor tooth or nares
Rationale: The endotracheal tube should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after endotracheal placement. The priority at this time is to verify that the tube has been correctly placed.
14. Answer: C. The patient’s blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min
Rationale: Removal of large quantities of fluid from the pleural space can cause fluid to shift from the circulation into the pleural space, causing hypotension and tachycardia. The patient may need to receive IV fluids to correct this. The other data indicate that the patient needs ongoing monitoring and/or interventions but would not be unusual findings for a patient with this diagnosis or after this procedure
15. Answer: A. Frequent swallowing
Rationale: Frequent swallowing after a tonsillectomy may indicate bleeding. You should inspect the back of the throat for evidence of bleeding. The other assessment results are not unusual in a 3-year old after surgery
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