Delegation
You are caring for a patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a medical technician?
A. Assisting the patient to sit up on the side of the bed.
B. Instructing patient on how to perform pursed-lip breathing.
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.
The clinical instructor directed the student nurse to care for a client whose potassium is 6.7 mEq/L. Which intervention should the student nurse anticipate?
A. Give potassium 10 mEq orally
B. Give sodium polystyrene sulfonate (Kayexalate) 15 g orally
C. Give spironolactone (Aldactone) 25 mg orally
D. Assess the electrocardiogram (ECG) strip for tall T waves
WHAT IS GIVE SODIUM POLYSTYRENE SULFONATE (KAYEXALATE) 15 G ORALLY
The nurse plans 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
WHAT IS RESPIRATORY STATUS
Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first?
A. Call for help to get the client back in bed
B. Establish whether the client is responsive
C. Assist the client back to bed
D. Ask the client what happened
WHAT IS ESTABLISH WHETHER THE CLIENT IS RESPONSIVE
A nurse enters a room and finds a patient lying face down on the floor and bleeding from a gash in the head. Which action should the nurse perform first?
A. Determine the level of consciousness
B. Push the call button for help
C. Turn the client face up to assess
D. Go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician
WHAT IS DETERMINE THE LEVEL OF CONSCIOUSNESS.
A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the medical technician?
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.
WHAT IS REMIND THE PATIENT TO SLEEP ON HIS SIDE INSTEAD OF HIS BACK.
The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced medical technician under your supervision? Select all that apply.
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.
WHAT IS A & C: OBSERVE HOW WELL THE PATIENT PERFORMS PURSED-LIP BREATHING.
The nurse 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. Check the patients perineal pad to determine extent of bleeding.
C. Give instructions regarding douching and sexual relations.
D. Administer pain medications.
WHAT IS CHECK THE PATIENTS PERINEAL PAD TO DETERMINE EXTENT OF BLEEDING.
A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the following assessment cues: pale, diaphoretic, blood pressure of 90/60, respirations of 33. The client is also anxious and fearing death. Which action should the nurse take first?
A. Administer pain medications
B. Administer IV fluids
C. Administer dopamine
D. Administer oxygen via nasal cannula
WHAT IS ADMINISTER OXYGEN VIA NASAL CANNULA.
You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an properly trained medical technician?
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
WHAT IS TAKING VITAL SIGNS AND PULSE OXIMETRY READINGS EVERY 4 HOURS
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.
WHAT IS A 50-YEAR OLD WITH ASTHMA WHO COMPLAINS OF SHORTNESS OF BREATH AFTER USING A BRONCHODILATOR.
When assessing a 22-year old patient who required emergency surgery and multiple transfusion 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.
WHAT IS SWITCH THE PATIENT TO A NONREBREATHER MASK AT 95% TO 100% OXYGEN AND CALL THE PHYSICIAN TO DISCUSS THE PATIENT’S STATUS.
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.
WHAT IS DECONTAMINATE THE OPEN WOUND ON THE CLIENT’S THIGH.
Nurse Pietro receives an 11-month old child with a fracture of the left femur on the pediatric unit. Which action is important for the nurse to take first?
A. Call for a social worker to meet with the family.
B. Check the child's blood pressure, pulse, respiration, and temperature.
C. Administer pain medications
D. Speak with the parents about how the fracture occurred.
WHAT IS SPEAK WITH THE PARENTS ABOUT HOW THE FRACTURE OCCURRED.
You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to a medical technician?
A. Teaching the patient about the importance of adequate fluid intake and hydration.
B. Assisting the patient in learning a new breathing position: 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.
WHAT IS REMINDING THE PATIENT TO USE AN INCENTIVE SPIROMETER EVERY 1 TO 2 HOURS WHILE AWAKE
The high-pressure alarm on a patient’s ventilator goes off. When you enter the room to assess the patient 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%
D. Insert an oral airway to prevent the patient from biting on the endotracheal tube.
WHAT IS MANUALLY VENTILATE THE PATIENT WHILE ASSESSING POSSIBLE REASONS FOR THE HIGH-PRESSURE ALARM.
Which intervention for a patient with a pulmonary embolus could be delegated to the medical technician 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. Checking the oxygen saturation every 4 hours.
WHAT IS CHECKING THE OXYGEN SATURATION EVERY 4 HOURS.
Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first?
A. A client with diabetes being discharged today.
B. A 35-year-old male with tracheostomy and copious secretions.
C. A teenager scheduled for physical therapy this morning.
D. A 78-year-old female client with a pressure ulcer that needs dressing change.
WHAT IS A 35-YEAR-OLD MALE WITH TRACHEOSTOMY AND COPIOUS SECRETIONS.
Nurse Skye is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?
A. A client scheduled for cardiac ultrasound this morning.
B. A client admitted with syncope being discharged today.
C. A client with acute bronchitis on nasal oxygen.
D. A client with diabetic foot ulcer that needs a dressing change
WHAT IS A CLIENT WITH ACUTE BRONCHITIS ON NASAL OXYGEN.
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 medical technician?
A. Initial patient instruction on proper alternation of rest and activity periods
B. Reminding, encouraging, monitoring, and recording nutritional intake
C. Monitoring cardiorespiratory response to new activity
D. Suctioning the patient prior to activity to promote tolerance
WHAT IS ENCOURAGING, MONITORING, AND RECORDING NUTRITIONAL INTAKE