Delegation & Prioritization
A CNA reports a postoperative patient has a respiratory rate of 8/min. What is the nurse’s priority action?
Assess the patient immediately (ABCs first)
What is an example of isotonic IV solution?
0.9% NaCl or Lactated Ringers
Normal range for the following: pH, CO2, HCO3, Na, and K?
pH: 7.35 - 7.45, CO2: 35 - 45, HCO3: 22 - 26(28), Na: 135 - 145 mEq/L, K: 3.5 - 5.0 mEq/L
Primary indication for suctioning?
Visible secretions or coarse crackles
Who is responsible for obtaining informed consent?
The provider (surgeon)
What are the five rights of delegation?
Right Task, Circumstance, Person, Direction/Communication, and Supervision/Evaluation
A patient receiving 3% NaCl develops crackles and dyspnea. What complication is suspected?
Fluid overload (pulmonary edema)
A client has been vomiting for two days. Which acid–base imbalance should the nurse anticipate?
Metabolic alkalosis
Maximum suction time for adults?
10 to 15 seconds
What is dehiscence?
Partial or complete separation of wound edges.
A patient has chest pain, another needs discharge teaching, and a third needs pain medication. Who do you see first?
Patient with chest pain (circulation priority)
You notice redness, warmth, and streaking at a peripheral IV site. What is this?
Phlebitis
A patient with hypokalemia reports muscle weakness and palpitations. What is your priority?
Cardiac monitoring
A trach patient becomes restless and oxygen saturation drops. First action?
Assess airway patency, apply oxygen, and suction if indicated.
What is your first action for evisceration?
Cover with sterile saline-moistened dressings
An LPN is caring for a stable patient with a PICC line. Which task can the RN delegate?
A. Initial assessment
B. Central line dressing change
C. Plan of care development
D. Blood administration verification
B – Dressing change (if agency policy allows)
A patient with a PICC has swelling in the arm. What is your concern?
Possible thrombosis or catheter occlusion
A patient presents to the ER with nausea and diarrhea for the past three days. What is the expected acid-base balance?
Metabolic acidosis
Continuous bubbling in the water seal chamber indicates what?
Air leak
A PCA patient is difficult to arouse and RR is 8/min. Priority?
Stop PCA and assess; prepare to administer naloxone.
Your CNA reports a patient “doesn’t look right.” Vital signs are pending. What is your best response?
Immediately assess the patient yourself.
Blood is ordered. What size IV is most appropriate?
At least a 20 gauge catheter
A client with potassium of 6.4 mEq/L is on telemetry. The monitor shows peaked T waves. The CNA reports the patient feels weak. The LPN asks if they should give the scheduled oral potassium. Identify the life-threatening problem AND state the immediate nursing intervention.
BONUS (100): Expected treatment.
Hyperkalemia. Hold the potassium. Notify the provider.
Bonus (100): CANDI-K
Chest tube accidentally disconnects. What should you do?
Place tubing in sterile water immediately.
Which intervention helps prevent atelectasis post-op?
Incentive spirometer use and early ambulation.