Nursing Management, Delegation and Prioritization 1

EXPLANATION

✔Correct answer:

Warfarin 1.0 mg by mouth (PO). Nurse Samuel should prioritize clarifying the warfarin order before administration due to the unnecessary use of a trailing zero (1.0 mg). The inclusion of a trailing zero after a decimal point creates a risk for medication errors, as it could be misinterpreted as 10 mg rather than 1 mg if the decimal point is overlooked. This violates safe medication administration practices, as outlined by The Joint Commission and the Institute for Safe Medication Practices (ISMP). The correct way to write this order would be “Warfarin 1 mg PO.” Nurse Samuel should confirm the correct dosage and request that the order be rewritten to eliminate the trailing zero before proceeding.

Warfarin is a high-alert medication with a narrow therapeutic index, meaning even small errors in dosing can have significant consequences, such as bleeding or thromboembolic events. Ensuring clarity in medication orders is a critical component of safe administration, particularly for anticoagulants like warfarin.

Writing a dosage with a trailing zero is like writing a check for $10.00 but mistakenly leaving out the decimal point—it could be misread as $100, leading to a significant error.

Nurse Samuel should follow these steps to ensure safe administration:

• Contact the prescribing physician to clarify and correct the warfarin order, eliminating the trailing zero.
• Verify the patient’s INR (International Normalized Ratio) level prior to administering warfarin to ensure the dose is appropriate for their coagulation status.
• Educate the patient about the purpose of warfarin, potential side effects, and the importance of adhering to prescribed dosages and follow-up INR monitoring.
• Document the clarification and updated order in the patient’s medical record.

✘Incorrect answer options:

Morphine sulfate 2 to 4 mg IV. This order is within acceptable parameters for pain management in a patient with a pulmonary embolism. Morphine can relieve chest pain and reduce anxiety, which may improve respiratory effort. The dosage range allows for titration based on the patient’s condition, and there is no need to clarify this order unless there is additional context indicating an issue.

Cephalexin 250 mg by mouth (PO). Cephalexin is an antibiotic, which may be prescribed prophylactically or for an underlying infection. This dosage is standard, and there is no indication that it requires clarification unless there is a concern about the patient’s allergies, infection type, or renal function.

Heparin infusion at 900 units/hr. This order appears consistent with typical dosing for a continuous heparin infusion to manage a pulmonary embolism. Unless there are concerns about the patient’s weight-based calculation, lab results (e.g., aPTT), or other clinical factors, this order does not require immediate clarification.

EXPLANATION

✔Correct answer:

Isolate the client in a designated decontamination area. In the event of a radiological incident, the first priority is to prevent the spread of contamination to others and minimize exposure. Isolating the client in a designated decontamination area ensures that radioactive particles are contained and that healthcare personnel and other patients are not exposed. This step is essential before performing any further assessments, treatments, or interventions. Decontamination, such as removing contaminated clothing and washing the skin, is necessary to reduce radiation exposure for both the patient and the healthcare team.

The primary goals in managing a radiological incident are to ensure safety, minimize contamination, and stabilize the patient. Containment of radioactive material takes precedence over treatment because unchecked contamination can exacerbate exposure and spread, leading to a larger public health risk.

Imagine someone tracking mud into a house after walking through wet dirt. Before cleaning the floors or helping the person, you first ask them to stop in one place (isolation) to prevent spreading the mud (contamination) to other rooms.

Nurse Clara should take the following steps to manage the situation:

• Quickly direct the client to a designated decontamination area to prevent further contamination.
• Ensure healthcare staff wear appropriate personal protective equipment (PPE) to protect themselves from exposure.
• Assist with decontamination procedures, such as removing clothing and washing the patient’s skin with soap and water to reduce radiation exposure.
• After containment and decontamination, assess the patient for injuries or other medical needs and provide necessary interventions.
• Collaborate with radiation safety officers and notify relevant departments, such as radiology and public health authorities.

✘Incorrect answer options:

Notify the radiology department to assist with contamination assessment. While involving the radiology department is important, it is not the first action Nurse Clara should take. Preventing the spread of contamination through isolation takes priority, as delaying this step could expose others to harmful radiation.

Perform a full physical examination to identify injuries. A physical examination is essential, but it is not the first priority in this scenario. The risk of spreading contamination must be mitigated before performing any detailed assessments, as exposure to radioactive material can endanger both the healthcare team and others in the vicinity.

Administer intravenous fluids to maintain hydration. Administering IV fluids may be part of supportive care, particularly if the patient is at risk for dehydration due to radiation sickness. However, this is not an immediate priority compared to isolating and decontaminating the patient to prevent further exposure and contamination.

EXPLANATION

✔Correct answer:

A 50-year-old with asthma reporting shortness of breath despite using a bronchodilator. Nurse Kim should prioritize seeing the patient with asthma who is reporting shortness of breath despite using a bronchodilator. Shortness of breath that does not resolve with a bronchodilator indicates that the patient may be experiencing an acute asthma exacerbation, which could quickly progress to life-threatening respiratory distress. This situation requires immediate assessment and intervention to prevent complications such as hypoxia or respiratory failure. The ABCs of prioritization (Airway, Breathing, Circulation) guide nurses to first address airway and breathing issues, making this patient the highest priority.

Asthma is a chronic inflammatory condition of the airways that causes bronchoconstriction, airway edema, and increased mucus production. In an exacerbation, the airways narrow further, leading to decreased airflow and oxygen exchange. Failure to respond to a bronchodilator suggests worsening obstruction or inflammation, requiring urgent treatment such as additional bronchodilators, corticosteroids, oxygen therapy, or in severe cases, mechanical ventilation.

Imagine an asthma exacerbation as a fire in a house (airways). A fire extinguisher (bronchodilator) is supposed to control the flames, but if the fire continues to grow, it signals an emergency requiring immediate action from firefighters (additional medical interventions).

Nurse Kim should prioritize this patient and focus on interventions to stabilize their breathing. Key actions include:

• Perform a focused respiratory assessment, including breath sounds, oxygen saturation, respiratory rate, and effort.
• Administer prescribed rescue medications, such as albuterol via nebulizer or inhaler.
• Provide oxygen therapy if saturation levels are low or symptoms worsen.
• Monitor for signs of respiratory distress, including accessory muscle use, cyanosis, or altered mental status.
• Notify the physician promptly if the patient does not respond to treatment.

✘Incorrect answer options:

A 60-year-old on a ventilator needing a sterile sputum sample sent to the lab. While this patient has important needs, collecting a sputum sample is not a time-sensitive intervention. This task can be addressed after stabilizing the patient with asthma who is in acute distress.

A 55-year-old with COPD and a prior pulse oximetry reading of 90% from the last shift. A pulse oximetry reading of 90% is consistent with the baseline oxygenation level for many COPD patients, as their bodies adapt to lower oxygen levels over time. This patient does not present an immediate emergency compared to the patient with worsening asthma.

A 70-year-old with pneumonia needing initiation of IV antibiotics. Timely initiation of IV antibiotics is essential for treating pneumonia, but a slight delay is unlikely to cause immediate harm. Respiratory distress in the asthma patient takes priority over this intervention.

EXPLANATION

✔Correct answer:

A 72-year-old patient requiring education on the use of incentive spirometry. Assigning a patient requiring education on incentive spirometry is the most appropriate choice for a nurse with six months of experience who has been temporarily reassigned from the surgical unit to the medical unit. This task aligns well with the nurse’s skill set and background, as incentive spirometry education is a straightforward intervention commonly encountered in both surgical and medical settings. It involves teaching the patient about lung expansion techniques to prevent postoperative complications like atelectasis, which is within the new nurse's scope and level of competence.

When assigning patients to a nurse with limited experience or a temporary reassignment, the nurse manager must ensure that the assignments match the nurse’s training and avoid overly complex or high-risk patients. Tasks requiring in-depth critical thinking, management of highly unstable patients, or specialized procedures should be assigned to more experienced nurses.

Assigning tasks to nurses is like pairing employees with projects in a workplace. You would assign simpler tasks like training on new tools (teaching incentive spirometry) to newer employees and save high-stakes or specialized tasks for seasoned workers.

When assigning this patient, Nurse Manager Smith should ensure that the new nurse:

• Receives support from the charge nurse or a mentor if questions arise about incentive spirometry teaching.
• Encourages the patient to use the incentive spirometer regularly and assesses the patient’s understanding and technique.
• Documents the patient’s response to teaching and ensures follow-up as needed.

✘Incorrect answer options:

A 58-year-old patient requiring airborne precautions for tuberculosis. Caring for a patient on airborne precautions for tuberculosis (TB) requires strict adherence to infection control protocols and poses a risk for errors if not managed correctly. While it is an important learning opportunity, it is not appropriate for a nurse with limited experience, especially in an unfamiliar unit.

A 68-year-old patient who recently underwent a bronchoscopy with biopsy. Post-bronchoscopy care involves monitoring for complications such as bleeding, respiratory distress, or pneumothorax, requiring careful assessment and timely intervention. This patient is more appropriate for a nurse with more experience in managing post-procedure complications.

A 69-year-old patient with COPD who is ventilator-dependent. Ventilator management requires specialized training, advanced assessment skills, and experience in caring for critically ill patients. A newer nurse may not yet have the competence or confidence to handle such a complex and high-risk patient safely.

EXPLANATION

✔Correct answer:

Manually ventilate Mr. Davis while investigating the cause of the high-pressure alarm. The high-pressure alarm on a ventilator typically indicates increased resistance to airflow or obstruction in the ventilator circuit. Combined with an oxygen saturation of 87%, this represents a potentially life-threatening situation that requires immediate action. Manually ventilating the patient with a bag-valve mask (BVM) allows the nurse to ensure adequate oxygenation and ventilation while troubleshooting the cause of the alarm. Possible causes include secretion buildup, patient agitation, or biting of the endotracheal tube. By manually ventilating, the nurse can bypass the ventilator to stabilize the patient while resolving the issue.

In patients with ARDS, stiff, non-compliant lungs can lead to difficulty ventilating even under normal circumstances. High-pressure alarms indicate that airflow is being restricted, which could further compromise gas exchange and exacerbate hypoxia. Immediate intervention is necessary to prevent rapid respiratory deterioration or cardiac arrest.

Imagine driving a car when suddenly the engine warning light comes on (the high-pressure alarm). You pull over immediately to prevent further damage (manual ventilation) while investigating what caused the issue, like overheating or low oil.

Nurse Kelly should follow these steps while addressing the high-pressure alarm:

• Disconnect the patient from the ventilator and manually ventilate with a BVM, ensuring oxygen is being delivered adequately.
• Quickly assess for potential causes, such as tube obstruction (mucus or biting), kinks in the ventilator tubing, or patient agitation.
• If obstruction is suspected, suction the endotracheal tube to remove secretions or clear blockages.
• Ensure that the patient is appropriately sedated if agitation or biting is contributing to the issue.
• Reconnect the patient to the ventilator once the issue is resolved and monitor closely for recurrence.

✘Incorrect answer options:

Reassure Mr. Davis that the ventilator will manage his breathing. Reassurance alone is not sufficient in this scenario. The ventilator is triggering a high-pressure alarm, and the patient has an oxygen saturation of 87%, indicating an urgent need to address the cause of the alarm. Immediate action to ensure oxygenation and ventilation is required.

Increase the fraction of inspired oxygen (FiO2) on the ventilator to 100% in anticipation of endotracheal suctioning. While increasing FiO2 may improve oxygenation temporarily, it does not address the underlying cause of the high-pressure alarm or the patient’s low oxygen saturation. Suctioning might be necessary, but the priority is to stabilize the patient with manual ventilation while troubleshooting.

Insert an oral airway to prevent Mr. Davis from biting the endotracheal tube. While biting the endotracheal tube is a potential cause of the high-pressure alarm, inserting an oral airway is not the immediate priority. The nurse must first manually ventilate to ensure oxygenation and assess whether biting is indeed the issue before proceeding with an oral airway.

EXPLANATION

✔Correct answer:

A tympanic temperature of 101.4°F (38.6°C). A temperature of 101.4°F (38.6°C) is indicative of a fever, which could signal an infection such as ventilator-associated pneumonia (VAP) in a patient on mechanical ventilation. Fever is an important finding in this context and requires immediate reporting to the nurse for further assessment and intervention. In mechanically ventilated patients, fever may also contribute to increased metabolic and oxygen demands, further stressing an already compromised respiratory system. Early identification and management of fever are critical to prevent worsening of the patient's condition.

Mechanical ventilation increases the risk of infections such as VAP due to factors like impaired airway clearance, colonization of the endotracheal tube, and prolonged hospital stay. Fever is a key sign of infection, and its presence necessitates immediate evaluation for potential sources, including respiratory cultures, chest X-rays, and blood work. Addressing fever promptly can help prevent complications like sepsis or acute respiratory distress.

Imagine a car engine overheating while already under heavy load (mechanical ventilation). The high temperature is a warning sign that something is wrong, and if not addressed quickly, it can cause further damage. Similarly, a fever in this patient signals a potential infection that must be addressed to avoid complications.

Upon being notified of the fever, Nurse Clara should take the following steps:

• Perform a thorough assessment of the patient, including lung sounds, oxygen saturation, and the presence of any other signs of infection (e.g., purulent secretions, increased WBC count).
• Notify the healthcare provider about the fever and potential need for diagnostic tests, such as a chest X-ray or sputum cultures.
• Administer antipyretics as prescribed to reduce the fever and enhance patient comfort.
• Implement infection prevention measures, such as ensuring strict aseptic technique during suctioning and maintaining oral care protocols.
• Continue monitoring the patient’s vital signs and respiratory status closely.

✘Incorrect answer options:

A heart rate of 98 beats per minute. A heart rate of 98 bpm is within the upper normal range for adults and does not immediately suggest an acute problem, especially in a critically ill patient. It does not require urgent reporting unless accompanied by other concerning signs.

A respiratory rate of 24 breaths per minute. A respiratory rate of 24 breaths per minute is slightly elevated but can be expected after suctioning due to temporary increased respiratory effort or agitation. While it should be monitored, it is not an urgent finding requiring immediate reporting.

A blood pressure reading of 168/90 mm Hg. Elevated blood pressure (hypertension) is a concern that requires monitoring, but it is not as urgent in this context as a fever in a ventilated patient. Hypertension could be related to pain, stress, or agitation and should be addressed after ensuring the fever is managed.

EXPLANATION

✔Correct answer:

Broccoli and similar vegetables. Nurse Elena should advise the client to avoid broccoli and other cruciferous vegetables (such as cauliflower, cabbage, and Brussels sprouts) because these foods are known to cause gas and bloating. These vegetables contain complex carbohydrates like raffinose, which are not fully digested in the small intestine. When they reach the colon, they are fermented by gut bacteria, producing gas as a byproduct. For individuals experiencing bloating, flatulence, and abdominal pain, limiting these foods can help alleviate symptoms.

The client’s symptoms of intermittent abdominal pain, bloating, and flatulence may be related to irritable bowel syndrome (IBS), food intolerance, or sensitivities to certain fermentable carbohydrates (e.g., FODMAPs—fermentable oligosaccharides, disaccharides, monosaccharides, and polyols). Reducing the intake of gas-producing vegetables is a common dietary strategy to manage these symptoms.

Think of the digestive system as a balloon. Eating gas-producing vegetables like broccoli is like blowing air into the balloon, causing it to stretch and feel uncomfortable. Avoiding these foods reduces the "air" and keeps the balloon (your digestive system) more comfortable.

Nurse Elena should educate the client on dietary modifications to manage their symptoms:

• Advise limiting cruciferous vegetables like broccoli, cabbage, and cauliflower, as well as other high-raffinose foods like beans and lentils.
• Encourage keeping a food diary to track potential triggers and identify patterns between symptoms and specific foods.
• Discuss other potential triggers, such as carbonated drinks or artificial sweeteners, that may worsen bloating and flatulence.
• If symptoms persist or worsen, recommend a referral to a registered dietitian for a more structured dietary approach, such as the low-FODMAP diet.
• Encourage hydration and regular physical activity to support healthy digestion.

✘Incorrect answer options:

High-fiber foods. While high-fiber foods can sometimes cause bloating, they are essential for overall digestive health and should not be avoided unless specifically identified as a trigger. Gradual introduction of fiber and adequate hydration can minimize bloating caused by fiber.

Yogurt or other cultured dairy products. Cultured dairy products like yogurt often contain probiotics, which may improve gut health and reduce bloating in some individuals. However, they should only be avoided if the client has a known intolerance to lactose or dairy.

Simple carbohydrate-rich foods. Simple carbohydrates are typically easy to digest and do not usually cause bloating or flatulence. However, excessive intake of refined sugars should be avoided for overall health. If symptoms are associated with specific simple sugars, such as fructose, these should be evaluated on an individual basis.

EXPLANATION

✔Correct answer:

Endotracheal intubation and initiation of mechanical ventilation. Acute Respiratory Distress Syndrome (ARDS) is a life-threatening condition characterized by severe hypoxia that persists despite supplemental oxygen therapy. When a non-rebreather mask, which delivers nearly 100% oxygen, fails to correct hypoxia, this indicates a need for advanced airway management. Endotracheal intubation and mechanical ventilation are essential to support oxygenation and ventilation while addressing the underlying pathophysiology of ARDS. Mechanical ventilation allows precise control of oxygen delivery, airway pressure, and tidal volume, which is critical in ARDS to minimize further lung injury (e.g., barotrauma, volutrauma) while ensuring adequate gas exchange.

ARDS occurs due to widespread alveolar damage, often triggered by systemic inflammation (e.g., sepsis, trauma, or aspiration). The damaged alveoli become flooded with protein-rich fluid, impairing gas exchange and leading to refractory hypoxemia (low blood oxygen levels unresponsive to oxygen therapy). Positive pressure ventilation through mechanical ventilation can help recruit collapsed alveoli, improve oxygenation, and maintain optimal gas exchange.

Imagine the lungs as a sponge that has been submerged in water (representing fluid-filled alveoli in ARDS). A non-rebreather mask is like trying to force air into the sponge through gentle blowing—it’s insufficient to push out the water and allow air to get in. Intubation and mechanical ventilation act like using a pump to pressurize the air and help squeeze the water out, allowing the sponge to function properly again.

Nurse Riley should anticipate and prepare for advanced airway management while continuing to monitor Mr. Thompson’s respiratory status closely. Here are the key considerations:

• Prepare for intubation by gathering necessary equipment (e.g., endotracheal tube, laryngoscope, suction equipment, and ventilator).
• Collaborate with the respiratory therapy team and the physician for timely intervention.
• Monitor arterial blood gases (ABGs) to evaluate the effectiveness of interventions and ventilator settings.
• Ensure appropriate sedation and pain management for patient comfort during mechanical ventilation.
• Regularly assess the patient for complications associated with mechanical ventilation, such as ventilator-associated pneumonia (VAP) or barotrauma.

✘Incorrect answer options:

Immediate application of continuous positive airway pressure (CPAP) via a nasal and oral mask. CPAP provides positive airway pressure throughout the respiratory cycle and can be helpful in some respiratory conditions, such as obstructive sleep apnea or early stages of hypoxemia. However, in ARDS with refractory hypoxia, CPAP alone is usually insufficient because it does not allow for the fine control of oxygenation, pressure, and ventilation needed to manage severe hypoxemia.

Administration of furosemide 100 mg intravenously as a bolus. While diuretics like furosemide may be used to manage fluid overload in conditions like pulmonary edema or heart failure, ARDS is primarily an inflammatory process. The hypoxemia in ARDS is not caused solely by fluid overload but by alveolar-capillary damage and fluid leakage into the alveoli. Furosemide is not the priority intervention in this scenario.

Activation of the emergency response system for respiratory arrest. Although Mr. Thompson’s condition is critical, he is not in respiratory arrest (characterized by the complete cessation of breathing) based on the information provided. The priority is advanced airway management (intubation and mechanical ventilation) to prevent respiratory arrest, not activation of a code response at this time.

EXPLANATION

✔Correct answers:

• "Use an electric razor instead of a traditional razor for shaving."
• "Avoid using dental floss and opt for a soft-bristled toothbrush instead."
• "Assist the patient with walking to reduce the risk of falls."

A patient receiving IV heparin therapy for a pulmonary embolism is at increased risk of bleeding due to the anticoagulant effects of heparin. Specific precautions are necessary to reduce the risk of injury and bleeding during activities of daily living:

1. Using an electric razor minimizes the risk of cuts and bleeding compared to traditional razors, which can accidentally nick the skin.
2. Avoiding dental floss and using a soft-bristled toothbrush helps prevent gum bleeding, which is a common source of bleeding in anticoagulated patients.
3. Assisting the patient with walking reduces the risk of falls. Patients on heparin are prone to excessive bleeding from even minor trauma, so fall prevention is a key safety measure.

These precautions align with evidence-based practices to protect patients receiving anticoagulant therapy from preventable complications.

Think of a patient on heparin therapy as walking a tightrope where any misstep (like a small injury) can lead to a larger issue. Safety measures, like using an electric razor and soft toothbrush, act like a safety net, minimizing risks and preventing problems before they occur.

Nurse Jackson should educate both the nursing assistant and the patient about safety measures related to anticoagulation therapy and ensure that care practices align with these guidelines.

• Teach the nursing assistant to closely monitor the patient for signs of bleeding, such as bruising, nosebleeds, or gum bleeding, and report any findings immediately.
• Encourage safe hygiene practices, including the use of soft-bristled toothbrushes and electric razors, to minimize the risk of cuts or mucosal injury.
• Supervise mobility and assist the patient as needed to prevent falls and related injuries.
• Educate the patient about the importance of adhering to safety precautions while receiving heparin therapy.

✘Incorrect answers:

"Encourage the patient to take frequent walks to prevent clot formation."  While ambulation is important for preventing clots in patients at risk for deep vein thrombosis (DVT), patients with a diagnosed pulmonary embolism are already receiving anticoagulation therapy to prevent clot propagation. Although walking is beneficial in recovery, it must be done cautiously and often with assistance to avoid falls. Encouraging independent walking without considering the patient's condition and bleeding risks is not the safest option in this scenario.

"Ensure the patient has compression stockings applied throughout the day." Compression stockings are typically used to prevent DVT or for patients with chronic venous insufficiency, but they are not routinely indicated for patients with an active pulmonary embolism already receiving anticoagulant therapy. The priority for a patient on heparin therapy is bleeding prevention, rather than compression, unless specifically ordered by the healthcare provider.

EXPLANATION

✔Correct answer:

Recommend humidifying the patient’s oxygen. Oxygen delivered via nasal cannula at flow rates of 4 L/min or higher can cause dryness and irritation of the nasal mucosa, leading to discomfort. Humidifying the oxygen helps to add moisture to the airflow, reducing dryness and enhancing the patient’s comfort. Humidification is a standard intervention for patients receiving higher-flow oxygen through a nasal cannula, as it prevents irritation and potential mucosal damage.

The nasal passages are lined with mucosa that naturally humidifies and warms the air we breathe. However, when oxygen is delivered at higher flow rates, it bypasses the body's ability to humidify the air adequately, leading to drying of the mucosa. This can cause discomfort, cracking, or even minor bleeding. Adding humidification mimics the body’s natural process, reducing irritation and promoting patient comfort.

Imagine breathing in air through your mouth on a cold winter day—it feels dry and uncomfortable. Now imagine sipping water to moisten your mouth—this is similar to what humidification does for oxygen therapy by adding moisture to the dry airflow.

Nurse Emily should take the following steps to ensure the patient’s comfort while maintaining effective oxygen therapy:

• Attach a humidification bottle to the oxygen delivery system to moisten the oxygen being delivered.
• Educate the patient about the purpose of humidification and how it alleviates discomfort.
• Assess the patient’s nasal passages for signs of dryness, irritation, or bleeding, and provide appropriate care if needed (e.g., nasal saline sprays).
• Ensure that the nasal cannula is properly fitted and not causing additional irritation due to improper placement.
• Reassess the patient’s comfort level after implementing humidification to determine its effectiveness.

✘Incorrect answer options:

Recommend switching to a simple face mask instead of a nasal cannula. A simple face mask may not improve the patient’s comfort and could potentially worsen the situation by covering the nose and mouth, causing claustrophobia or additional discomfort. It is also unnecessary unless the patient’s oxygen needs exceed what can be delivered through a nasal cannula.

Recommend providing an additional pillow for the patient. While positioning adjustments, such as providing an additional pillow, may improve overall comfort or respiratory mechanics, this intervention does not directly address the dryness and nasal discomfort caused by oxygen therapy.

Recommend having the patient sit upright in a chair at the bedside. Encouraging a patient to sit upright can improve oxygenation by enhancing lung expansion, but it does not resolve the specific issue of nasal discomfort caused by high-flow oxygen therapy.

EXPLANATION

✔Correct answers:

• A 38-year-old with moderate persistent asthma who is preparing for discharge.
• A 63-year-old with a tracheostomy requiring routine tracheostomy care every shift.

Assigning patients to a newly graduated RN should be based on the patient's complexity and the nurse's current skill level and confidence. Patients with relatively stable conditions or predictable care needs are more appropriate assignments, allowing the new nurse to develop clinical skills without becoming overwhelmed by more complex or unstable cases.

• A 38-year-old with moderate persistent asthma who is preparing for discharge: This patient is stable and near discharge, which provides an opportunity for the new RN to practice teaching and discharge planning, critical skills in nursing practice. Teaching about asthma management, medication use (e.g., MDIs), and recognizing exacerbation symptoms are appropriate responsibilities for a new nurse under supervision.
• A 63-year-old with a tracheostomy requiring routine tracheostomy care every shift: This patient has predictable care needs, such as routine tracheostomy care, suctioning, and monitoring for respiratory complications. These tasks provide the new RN with hands-on practice in essential skills that are commonly encountered in hospital settings, making this a suitable assignment under supervision.

Assigning patients to a newly graduated nurse is like teaching someone to drive. You want them to practice on straightforward roads (predictable, stable patients) before navigating highways or intersections with heavy traffic (unstable or complex patients). This ensures they build confidence and competency safely.

Nurse Jenna should provide oversight, guidance, and opportunities for learning to the new graduate while ensuring patient safety.

• Encourage the new RN to focus on time management, patient teaching, and technical skills such as tracheostomy care.
• Provide feedback on documentation, patient education, and bedside care to reinforce clinical judgment and communication skills.
• Monitor the new RN’s ability to recognize changes in patient condition and escalate concerns appropriately.
• Gradually introduce more complex assignments as the new RN demonstrates competence and confidence.

✘Incorrect answer options:

A 56-year-old with lung cancer who recently had a left lower lobectomy. This patient is in the postoperative phase following a major thoracic surgery, making them a more complex and high-risk assignment. The patient will require close monitoring for complications such as respiratory distress, bleeding, and infection. A more experienced nurse should handle this patient due to the need for advanced assessment skills and quick critical thinking.

A 49-year-old who has just been admitted with a new diagnosis of esophageal cancer. Newly admitted patients require comprehensive assessments, care planning, and coordination of diagnostic tests, which demand advanced organizational skills and experience. In addition, the emotional and informational needs of a patient newly diagnosed with cancer require a nurse with strong therapeutic communication and teaching skills. This patient is not appropriate for a newly graduated RN.

EXPLANATION

✔Correct answer:

Administer prescribed bronchodilator medications via nebulizer. Administering prescribed bronchodilator medications via nebulizer is the most appropriate task for Nurse Sarah to delegate to the experienced LPN. Medication administration is a routine and essential task within the LPN’s scope of practice. This task requires technical skills but does not involve the higher-level critical thinking or decision-making that remains the responsibility of the RN. Delegating this task allows the RN to focus on more complex responsibilities, such as assessing the patient’s respiratory status, creating a care plan, and providing patient education.

When delegating tasks, the RN must ensure the LPN is competent and understands the patient-specific context of the task. The LPN should also be directed to monitor the patient’s response to the medication and report any adverse effects or lack of improvement.

Think of an RN as a team leader delegating tasks to skilled team members. The leader focuses on planning and problem-solving, while team members handle routine tasks like delivering supplies (administering nebulized medication) to keep the operation running smoothly.

Nurse Sarah should ensure that the LPN is adequately supported and prepared for this task. Key points include:

• Provide clear instructions on the timing and proper administration of the bronchodilator medication via nebulizer.
• Instruct the LPN to monitor for therapeutic effects, such as improved airflow, and side effects like tachycardia or tremors.
• Ensure the LPN knows to report back on the patient’s response to the treatment or any concerning signs, such as worsening dyspnea or oxygen desaturation.

✘Incorrect answer options:

Assess the patient’s respiratory status and report findings to the healthcare provider. Assessment is a key component of the RN’s responsibilities and requires critical thinking and analysis. While the LPN can collect data (e.g., measure vital signs), the RN is responsible for interpreting the findings and communicating with the healthcare provider.

Develop a care plan to address the patient’s ineffective breathing pattern. Care planning requires the RN’s professional judgment and ability to prioritize and tailor interventions to the patient’s needs. LPNs can assist in implementing the care plan but cannot develop it independently.

Teach the patient pursed-lip breathing to improve ventilation. Teaching is an advanced skill that involves assessment, education, and evaluation of the patient’s understanding. This task requires the RN’s expertise, as it includes explaining the purpose of the technique and ensuring proper execution by the patient.

EXPLANATION

✔Correct answer:

Assisting Mrs. Rodriguez to sit up on the edge of the bed. The most appropriate task to delegate to a nursing assistant is assisting the patient with repositioning, such as helping Mrs. Rodriguez sit up on the edge of the bed. Repositioning promotes better lung expansion and facilitates airway clearance in patients with COPD. This task falls within the scope of practice for nursing assistants, as it involves providing physical assistance rather than performing assessments or education, which are responsibilities reserved for licensed nurses (RNs or LPNs).

When delegating tasks, it is essential to consider the nursing assistant’s scope of practice, skill level, and training. Tasks that require critical thinking, patient education, or assessment should not be delegated to unlicensed assistive personnel (UAP). Assisting with positioning is a routine, non-invasive task that supports the patient’s care plan and can safely be delegated.

Delegation in nursing is like assigning jobs during a team project. While the team leader handles decision-making and planning (assessment, education), other team members can assist with support tasks, such as arranging materials (repositioning) to help the leader meet the project goals efficiently.

Delegation of tasks must be accompanied by appropriate supervision and follow-up to ensure quality care. Nurse Chen should consider the following points:

• Clearly communicate to the nursing assistant the importance of proper positioning for Mrs. Rodriguez’s respiratory function.
• Monitor the patient after repositioning to assess for improvements in breathing and comfort.
• Provide guidance if the nursing assistant has any questions or concerns about the task.
• Continue to perform assessments and higher-level interventions as the RN, such as teaching or auscultating lung sounds.

✘Incorrect answer options:

Instructing Mrs. Rodriguez on effective coughing techniques. This task involves patient education, which requires critical thinking and professional judgment to ensure the patient understands the technique and can perform it safely. Only licensed nurses (RNs or LPNs) should provide this type of instruction.

Teaching Mrs. Rodriguez how to use incentive spirometry. Teaching patients how to use medical equipment, such as an incentive spirometer, also involves patient education and assessment of their understanding and technique. This is outside the scope of practice for nursing assistants and must be performed by a licensed nurse.

Auscultating Mrs. Rodriguez’s breath sounds every four hours. Auscultation is an assessment skill requiring clinical knowledge and training to evaluate the patient’s respiratory status accurately. It is a responsibility of the RN or LPN and cannot be delegated to a nursing assistant.

EXPLANATION

✔Correct answer:

Surfactant. The medication Nurse Rachel should anticipate administering to improve the newborn’s respiratory status is surfactant. Respiratory Distress Syndrome (RDS) in newborns occurs due to a deficiency of surfactant, a substance produced in the lungs that reduces surface tension and prevents alveoli from collapsing. Surfactant replacement therapy is the standard treatment for infants with RDS, particularly preterm infants, as their lungs are often underdeveloped and unable to produce sufficient amounts of surfactant. Administering surfactant improves lung compliance, oxygenation, and ventilation, helping the newborn breathe more effectively.

In RDS, the lack of surfactant leads to increased alveolar surface tension, resulting in alveolar collapse (atelectasis). This impairs gas exchange and leads to hypoxia, hypercapnia, and respiratory failure. Surfactant replacement is typically delivered directly into the lungs via an endotracheal tube, and it rapidly reduces alveolar collapse and improves lung function.

Think of the alveoli as tiny balloons that need a coating to prevent them from sticking together when deflated. Surfactant acts like a lubricant, ensuring the balloons can reinflate easily and continue functioning without collapsing.

Nurse Rachel should follow these steps when administering or monitoring the effects of surfactant therapy:

• Assist with the preparation and administration of surfactant therapy, ensuring the correct dosage is delivered via endotracheal tube.
• Closely monitor the newborn’s respiratory status before, during, and after administration, including oxygen saturation, respiratory rate, and breath sounds.
• Observe for potential complications of surfactant therapy, such as transient bradycardia, oxygen desaturation, or endotracheal tube obstruction.
• Support the infant’s oxygen and ventilation needs, adjusting mechanical ventilation settings as necessary following surfactant administration.
• Educate the parents about RDS, the purpose of surfactant therapy, and the expected improvements in the infant’s condition.

✘Incorrect answer options:

Theophylline. Theophylline is a methylxanthine used to treat apnea of prematurity and some chronic respiratory conditions like asthma or COPD. However, it is not effective in treating RDS in newborns, as it does not address the surfactant deficiency that underlies the condition.

Dexamethasone. Dexamethasone is a corticosteroid that may be used prenatally to promote fetal lung maturity in mothers at risk for preterm delivery. However, it is not a direct treatment for RDS in the newborn after birth. Surfactant therapy is more immediate and specific to managing the acute respiratory compromise in RDS.

Albuterol. Albuterol is a bronchodilator commonly used to manage bronchospasm in conditions such as asthma or COPD. It is not used to treat RDS because RDS is related to surfactant deficiency, not bronchospasm or airway obstruction.

EXPLANATION

✔Correct answer:

Administer postural drainage and chest physiotherapy every four hours. Cystic fibrosis (CF) is a genetic condition that leads to the production of thick, sticky mucus in the lungs, making it difficult to clear airway secretions. This predisposes patients to recurrent respiratory infections, like pneumonia, and chronic respiratory issues such as dyspnea. The priority nursing intervention for Sarah, who is experiencing worsening respiratory symptoms, is to facilitate effective airway clearance. Postural drainage and chest physiotherapy are key therapies in CF management, as they help mobilize and remove secretions from the lungs, improving oxygenation and reducing the risk of further respiratory compromise.

In CF, a mutation in the CFTR gene causes abnormal chloride and sodium transport across cell membranes, resulting in thickened mucus. This mucus obstructs the airways and provides a breeding ground for bacterial infections, which exacerbate inflammation and respiratory distress. Timely and consistent airway clearance measures are essential in managing these complications.

Imagine the lungs as a highway system and mucus as a traffic jam blocking the flow of cars (air). Postural drainage and chest physiotherapy work like tow trucks clearing the obstruction, ensuring that cars (air) can move freely again.

Supporting Sarah's airway clearance and managing her respiratory status is critical. Below are some key nursing interventions to consider:

• Perform postural drainage and chest physiotherapy as prescribed, ideally every four hours or more frequently during acute respiratory distress.
• Administer prescribed bronchodilators or mucolytics before chest physiotherapy to loosen mucus and optimize airway clearance.
• Monitor oxygen saturation levels and provide supplemental oxygen if needed.
• Encourage adequate hydration to help thin mucus secretions.
• Educate Sarah and her family about airway clearance techniques and the importance of adherence to her treatment regimen.

✘Incorrect answer options:

Allow Sarah to self-administer aerosolized medications based on her perceived need. While encouraging independence is important for adolescents with chronic illnesses, aerosolized medications such as bronchodilators and mucolytics need to be administered on a scheduled basis to ensure effective airway clearance and prevent worsening of symptoms. Self-administration "as needed" could lead to inconsistent treatment and suboptimal outcomes.

Place Sarah in a private room to minimize the risk of cross-contamination. Although infection control is a significant concern for patients with CF (especially to avoid cross-infection with other CF patients due to pathogens like Pseudomonas aeruginosa), this intervention is secondary to addressing Sarah’s immediate respiratory distress and ensuring effective airway clearance.

Schedule activities to ensure at least eight hours of continuous sleep. Adequate rest is essential for patients with chronic conditions, but during acute exacerbations, airway clearance therapies and treatments take precedence over prolonged uninterrupted rest. Additionally, lying flat for extended periods could worsen secretion retention, further compromising respiratory function.

EXPLANATION

✔Correct answer:

4, 1, 2, 3. Proper use of a metered-dose inhaler (MDI) involves a sequential process to ensure that the medication is delivered effectively into the lungs. Here’s the correct order of steps:

• Exhale completely before using the inhaler: Exhaling first ensures that the lungs are empty, creating space to inhale the medication deeply and efficiently.
• Shake the inhaler and remove the cap: Shaking the inhaler mixes the medication properly, ensuring an even dose is delivered when the device is activated. Removing the cap allows access to the mouthpiece.
• Place the inhaler mouthpiece in the mouth and press the inhaler while inhaling slowly and deeply: Coordinating the pressing of the inhaler and slow, deep inhalation helps the medication reach the lower airways where it is most effective.
• Hold breath for about 10 seconds after inhaling the medication: Holding the breath allows the medication to settle in the lungs and enhances absorption.

This sequence maximizes the effectiveness of the medication while minimizing waste or improper technique.

Think of using an MDI like drinking from a straw in a juice box. First, you need to empty your mouth of air (exhale), shake the box (mix the contents), align the straw (mouthpiece) properly, and then take a slow, steady sip (inhale medication). Holding the "sip" in your mouth for a moment helps you taste it fully, just like holding your breath allows the medication to work better.

Nurse Julia should ensure the student nurse understands the steps and is able to demonstrate proper technique to the patient.

• Observe the student nurse teaching the technique and provide feedback to ensure the patient receives clear and accurate instructions.
• Emphasize the importance of timing and coordination when pressing the inhaler and inhaling to achieve the best therapeutic outcomes.
• Reinforce the need for patients to clean the inhaler regularly to prevent clogs and ensure proper dosing.

✘Incorrect answer options:

4, 2, 1, 3. Placing the mouthpiece in the mouth and pressing the inhaler (Step 2) before shaking it and removing the cap (Step 1) skips a crucial step needed to mix the medication properly. This sequence is incorrect.

1, 2, 3, 4. Starting with shaking the inhaler (Step 1) is correct, but this sequence skips the step of exhaling first (Step 4), which is essential to prepare the lungs to fully receive the medication.

4, 1, 3, 2. While this option starts with exhaling (Step 4) and shaking the inhaler (Step 1), it incorrectly places holding the breath (Step 3) before inhaling the medication (Step 2). Holding the breath can only happen after the medication is inhaled.

EXPLANATION

✔Correct answer:

Reminding Mr. Johnson to maintain a lateral (side-lying) sleeping position. The most appropriate intervention for delegation to a nursing assistant is reminding Mr. Johnson to maintain a lateral (side-lying) sleeping position. Patients with sleep apnea often experience airway obstruction when lying in the supine position due to gravity's effect on the tongue and soft tissues of the throat. A side-lying position helps reduce airway obstruction and promotes better airflow during sleep. This task involves simple reinforcement of a pre-established care plan, which is within the scope of practice for nursing assistants.

Tasks that involve reinforcing established routines or instructions can be safely delegated to unlicensed assistive personnel (UAP). The RN, however, retains responsibility for assessing the patient’s condition, developing the care plan, and providing any initial or advanced education.

Imagine a basketball coach (the RN) creating a game plan for the team, assigning roles to players based on their abilities. The coach handles the strategy (education and advanced care tasks), but tasks like reminding players to stay hydrated during the game (reinforcing simple instructions like side-lying sleep position) can be delegated to an assistant coach (the nursing assistant). Both work together to ensure the team's success without compromising the coach’s responsibilities or the players' performance.

Nurse Thompson should provide clear instructions to the nursing assistant regarding the importance of side-lying position and monitor Mr. Johnson’s progress. Key considerations include:

• Explain to the nursing assistant why the lateral position is important for reducing airway obstruction in sleep apnea.
• Verify that Mr. Johnson understands the need for this position and has the appropriate bedding or pillows for support.
• Monitor for any changes in Mr. Johnson’s sleep patterns or symptoms that might require reassessment of his care plan.

✘Incorrect answer options:

Discussing weight-loss strategies, including diet and exercise, with Mr. Johnson. Discussing lifestyle modifications such as weight-loss strategies involves patient education and planning, which require professional knowledge and critical thinking. These tasks fall under the scope of the RN or LPN and should not be delegated to a nursing assistant.

Teaching Mr. Johnson how to set up the BiPAP machine before sleep. Teaching a patient how to properly use a BiPAP machine requires specialized knowledge and training to ensure the patient understands the setup, operation, and troubleshooting of the equipment. This task must be performed by a licensed nurse or respiratory therapist, not a nursing assistant.

Administering modafinil to promote daytime wakefulness. Administering medications is a clinical task that requires assessment, monitoring, and appropriate licensure. It is outside the scope of practice for nursing assistants and must be completed by a licensed nurse.

EXPLANATION

✔Correct answer:

A patient two days post-total hip replacement requiring blood glucose checks. Nurse Jenna, a medical-surgical nurse with no prior orthopedic experience, should be assigned to the patient two days post-total hip replacement who requires blood glucose checks. This patient is the most stable and requires routine care that aligns with Nurse Jenna’s skill set. Monitoring blood glucose levels is a common nursing task on any unit, and this patient does not present acute complications or require specialized orthopedic knowledge.

When nurses are floated to units outside their specialty, they should be assigned stable patients whose needs are similar to those encountered in their home unit. This approach ensures patient safety and allows the nurse to work within their scope of practice and experience.

Think of floating as assigning a chef trained in Italian cuisine to a general kitchen. While they can manage basic tasks like making a sandwich (routine blood glucose checks), asking them to prepare a specialized dish like sushi (orthopedic-specific care) could compromise the quality of the outcome.

Nurse Jenna’s care for this patient should include the following:

• Perform blood glucose monitoring as scheduled and report any abnormal findings to the healthcare provider.
• Assess the patient’s pain level and mobility, which are part of routine postoperative care for a total hip replacement.
• Reinforce hip precautions to prevent complications, such as dislocation, based on any education provided by orthopedic staff.
• Provide routine postoperative care, such as monitoring for signs of infection or thrombosis, which are common in medical-surgical settings.

✘Incorrect answer options:

A patient with a cast for a fractured femur experiencing numbness and toe discoloration. This patient is exhibiting signs of potential compartment syndrome, a medical emergency requiring immediate intervention to prevent permanent nerve or tissue damage. Managing this complication requires specialized orthopedic knowledge and experience, making it unsuitable for Nurse Jenna.

A patient in balanced skeletal traction who requires assistance with morning care. Caring for a patient in skeletal traction involves specialized knowledge of traction systems, including how to maintain alignment, ensure pin site care, and prevent complications like infection or skin breakdown. Without prior orthopedic experience, Nurse Jenna may not be prepared to safely care for this patient.

A patient post-above-knee amputation (yesterday) with a fever of 101.4°F. A postoperative fever may indicate an infection or other complications, requiring a thorough understanding of post-amputation care, including wound management and potential prosthetic concerns. This patient is more appropriate for an experienced orthopedic nurse.

EXPLANATION

✔Correct answer:

Switch to a nonrebreather mask at 95%-100% oxygen and notify the physician about the patient’s condition. The patient’s labored breathing, tachypnea (respiratory rate of 38 breaths/min), and oxygen saturation of 90% despite 6 L/min of oxygen via nasal cannula indicate severe hypoxemia, possibly due to Acute Respiratory Distress Syndrome (ARDS), transfusion-related acute lung injury (TRALI), or other postoperative complications such as pulmonary edema. Switching to a nonrebreather mask provides a higher concentration of oxygen (up to 95%-100%) compared to a nasal cannula and is a critical step to stabilize oxygenation while preparing for further interventions. Notifying the physician immediately is essential, as this condition may require advanced management, such as noninvasive ventilation, intubation, or addressing the underlying cause.

In conditions like ARDS or TRALI, inflammation and increased capillary permeability lead to fluid leakage into the alveoli, impairing gas exchange. Oxygen therapy via a nasal cannula is insufficient to meet the patient’s oxygenation needs in this scenario. A nonrebreather mask delivers a higher oxygen concentration and can temporarily stabilize the patient until definitive treatment is initiated.

Imagine trying to fill a leaky balloon (the lungs) with a low-powered air pump (nasal cannula). The pump won’t provide enough force or volume to inflate the balloon. Switching to a more powerful pump (nonrebreather mask) allows you to compensate for the leak and stabilize the situation temporarily.

Nurse Jordan should prioritize stabilizing the patient’s oxygenation and addressing the root cause of their condition. Key steps include:

• Switch the patient to a nonrebreather mask to deliver the highest possible oxygen concentration.
• Perform a rapid assessment of the patient’s respiratory effort, auscultate lung sounds, and check for signs of fluid overload or pulmonary complications.
• Notify the physician immediately and anticipate orders for diagnostic tests such as arterial blood gases (ABGs), chest X-ray, or laboratory studies.
• Prepare for possible advanced airway management, such as intubation or mechanical ventilation, if the patient’s condition worsens.
• Monitor closely for signs of further respiratory deterioration or complications.

✘Incorrect answer options:

Increase the oxygen flow rate to 10 L/min via nasal cannula and reassess in 10 minutes. A nasal cannula can deliver only a limited oxygen concentration (approximately 44% at 6 L/min). Increasing the flow rate to 10 L/min would not significantly improve oxygenation in a patient with severe hypoxemia and labored breathing. Immediate action to deliver a higher oxygen concentration via a nonrebreather mask is more appropriate.

Encourage the use of an incentive spirometer and have the patient splint the chest with a pillow while coughing. Incentive spirometry and coughing are effective for preventing atelectasis and promoting lung expansion in stable postoperative patients. However, they are inappropriate for a patient in severe respiratory distress, as they do not address the critical hypoxemia requiring urgent oxygen therapy.

Administer the prescribed morphine sulfate to decrease anxiety and reduce hyperventilation. Administering morphine in this situation could depress the patient’s respiratory drive, worsening hypoxemia. While morphine can be helpful in specific conditions like acute pulmonary edema, it is contraindicated here due to the patient’s labored breathing and low oxygen saturation.

EXPLANATION

✔Correct answer:

Ensure the client has signed the informed consent form. The first priority before any procedure, including a colposcopy, is to ensure that the client has provided informed consent. Informed consent is a legal and ethical requirement, as it confirms that the client understands the purpose, risks, benefits, and alternatives to the procedure and agrees to proceed. Nurse Sarah must verify that the client has signed the informed consent form before any preparation or interventions take place. This ensures respect for the client’s autonomy and protects the healthcare provider from legal liability.

The provider performing the colposcopy is responsible for explaining the procedure to the client and obtaining their consent. However, it is the nurse's responsibility to verify that the signed consent form is present in the client’s chart and that the client has no unanswered questions before proceeding.

Ensuring informed consent is like checking that a traveler has their boarding pass before allowing them to board a plane. It’s a mandatory step to confirm that everything is in order before moving forward.

Nurse Sarah should follow these steps when preparing the client for the colposcopy:

• Confirm that the informed consent form is signed and present in the client’s medical record.
• Verify that the client understands the procedure and address any remaining questions or concerns.
• Provide emotional support to reduce anxiety and establish trust with the client.
• Once consent is verified, proceed with further preparation, such as positioning the client and offering relaxation measures.
• Document that the informed consent was verified and any pre-procedure interventions provided.

✘Incorrect answer options:

Explain the steps of the procedure in detail to the client. While explaining the procedure is important for reducing anxiety, it is not the nurse's primary responsibility to provide a detailed explanation. The provider performing the procedure is responsible for this step. The nurse should verify informed consent first and then provide additional explanations as needed.

Offer a mild sedative to help the client relax. Sedation is not routinely required for a colposcopy and would need a specific order from the healthcare provider. Additionally, this step would occur after verifying informed consent.

Position the client on the examination table for the procedure. Positioning the client is a necessary step to prepare for the procedure, but it should occur only after confirming that informed consent has been obtained and documented.

EXPLANATION

✔Correct answer:

An oral temperature of 101.2°F (38.4°C). An oral temperature of 101.2°F (38.4°C) is the most concerning vital sign in a patient with COPD. A fever in this patient population may indicate an underlying infection, such as influenza, pneumonia, or another respiratory infection, which can exacerbate their condition. Patients with COPD already have compromised lung function, and infections can lead to worsening respiratory distress, increased mucus production, and hypoxemia. Prompt reporting and intervention are critical to prevent further complications, such as acute respiratory failure or sepsis.

COPD affects the lungs' ability to clear mucus and fight off infections. Missing vaccinations for influenza and pneumonia increases the risk of these infections, which can cause inflammation and further compromise oxygen exchange. A fever reflects the body’s inflammatory response to an infection and often coincides with increased respiratory demands, which can be particularly dangerous for COPD patients.

Think of a COPD patient's lungs as a fragile engine that struggles to function under normal conditions. A fever is like overheating the engine due to added strain, signaling that immediate attention is needed to prevent further damage.

Nurse Elena should assess the patient promptly upon being informed of the fever and take the following steps:

• Perform a focused respiratory assessment, including lung sounds, oxygen saturation, respiratory rate, and effort.
• Notify the healthcare provider immediately to initiate diagnostic tests (e.g., sputum culture, chest X-ray, blood work) and determine appropriate treatment.
• Administer antipyretics as prescribed to reduce fever and monitor the patient’s response.
• Encourage adequate fluid intake to support hydration and mucus clearance, as tolerated by the patient.
• Closely monitor the patient for signs of respiratory decompensation, such as increased work of breathing, accessory muscle use, or decreased oxygen saturation.

✘Incorrect answer options:

A blood pressure reading of 152/84 mm Hg. While this blood pressure reading is elevated (stage 2 hypertension), it does not pose an immediate threat in the context of COPD. Blood pressure management can be addressed after addressing more urgent concerns, such as a fever that may signal infection.

A respiratory rate of 27 breaths per minute. An elevated respiratory rate is expected in patients with COPD, especially if they are experiencing exertion or mild distress. While it should be monitored, it does not require immediate reporting unless it is significantly higher or accompanied by other signs of acute distress, such as hypoxemia.

A heart rate of 92 beats per minute. A heart rate of 92 bpm is within normal limits for adults and does not require urgent attention. In COPD patients, tachycardia (heart rate >100 bpm) could indicate hypoxia or stress, but this reading alone is not concerning in this case.

EXPLANATION

✔Correct answers:

• Auscultate breath sounds.
• Administer medications via metered-dose inhaler (MDI).

An experienced Licensed Practical Nurse (LPN) operates within a defined scope of practice that includes certain assessment and medication administration tasks.

1. Auscultate breath sounds: LPNs are trained to perform focused assessments, such as listening to lung sounds and documenting findings. However, they cannot interpret or diagnose based on these findings, which must be reviewed by an RN.
2. Administer medications via metered-dose inhaler (MDI): LPNs are authorized to administer medications, including MDIs, as part of their routine duties. This task is appropriate and falls within their scope of practice, provided the medication has been prescribed and is not experimental.

These tasks utilize the LPN’s clinical skills and training without requiring advanced critical thinking or independent decision-making, which are typically reserved for RNs.

Think of the LPN as a skilled driver following a detailed map (care plan). They can safely perform tasks like checking the engine (auscultating breath sounds) and refueling the car (administering medications), but creating the map (care plan) or deciding when to change routes (evaluating care) requires a navigator (RN).

Nurse Maria should ensure that the LPN is working within their scope of practice while the RN retains responsibility for care coordination, advanced assessment, and patient education.

• Supervise the LPN’s tasks, such as auscultation and medication administration, to ensure competency and accuracy.
• Review the LPN’s findings (e.g., breath sounds) and incorporate them into the overall assessment and care plan.
• Provide guidance to the LPN when tasks require advanced clinical judgment or involve patient education, ensuring the RN is available for such duties.

✘Incorrect answer options:

Complete in-depth admission assessment. Admission assessments require comprehensive data collection and interpretation, which fall under the RN’s scope of practice. LPNs can collect specific data as part of focused assessments, but they cannot perform the complete and in-depth evaluation required during patient admission.

Initiate the nursing care plan. LPNs can contribute to the nursing care plan by providing input and performing interventions outlined in the plan, but initiating the care plan is the responsibility of the RN, who has the critical thinking skills and training to develop and prioritize care goals.

Evaluate the patient’s technique for using MDIs. While LPNs can assist and teach patients about using MDIs, evaluating the patient’s technique is a higher-level skill that involves clinical judgment and assessing effectiveness, which falls under the RN’s responsibilities. The RN must ensure that the patient is using the inhaler correctly to achieve therapeutic outcomes.

EXPLANATION

✔Correct answer:

"I will keep taking my isoniazid until I feel completely better." This statement indicates the need for further teaching because tuberculosis (TB) treatment must be continued for the full prescribed duration, typically 6-9 months, even if the patient starts feeling better. Stopping TB medications prematurely increases the risk of treatment failure, drug resistance (e.g., multidrug-resistant TB), and relapse of the infection. Patients need to understand the importance of adherence to the complete course of therapy, even in the absence of symptoms.

TB is caused by Mycobacterium tuberculosis, a slow-growing bacterium that requires long-term antibiotic therapy to eradicate. Medications like isoniazid target active and dormant bacteria, but incomplete treatment can allow resistant strains to develop, complicating future treatment. Patient education is essential to promote adherence and prevent public health risks.

Treating TB is like removing weeds from a garden. Even if the visible weeds are gone (symptoms improve), you must continue treating the soil for the full season to ensure that dormant weed seeds (latent bacteria) don’t regrow and take over again.

Nurse Amanda should emphasize these key points during discharge teaching:

• Explain the critical importance of completing the full course of TB medications, regardless of symptom improvement.
• Provide a written schedule of medications and discuss potential side effects to improve adherence.
• Encourage the patient to use directly observed therapy (DOT), if available, to ensure compliance with treatment.
• Reiterate the need for follow-up appointments to monitor progress and evaluate treatment effectiveness.
• Stress the importance of infection prevention measures to protect others until the patient is no longer infectious.

✘Incorrect answer options:

"Everyone in my household needs to see a doctor for TB testing." This statement demonstrates correct understanding. Close contacts of individuals with TB should undergo screening, such as a tuberculin skin test (TST) or interferon-gamma release assay (IGRA), to determine if they have been exposed or infected.

"I’ll cover my mouth and nose when sneezing or coughing and dispose of tissues properly." This statement reflects proper infection control practices. Covering the mouth and nose reduces the risk of spreading TB bacteria through airborne droplets, and disposing of tissues appropriately minimizes contamination.

"I’ll adjust my diet to include more iron, protein, and vitamin C." This statement shows an understanding of the importance of nutritional support in TB treatment. A well-balanced diet helps strengthen the immune system and promotes recovery, which is especially important for patients with chronic infections like TB.

EXPLANATION

✔Correct answer:

The client’s respiratory status. Upon transfer to the post-anesthesia care unit (PACU), the priority assessment for Nurse Mia is the client’s respiratory status. The primary concern in the immediate postoperative period is ensuring airway patency and adequate ventilation, as anesthesia can depress respiratory drive and compromise airway protection. Evaluating respiratory status includes checking the airway for patency, observing respiratory effort, measuring oxygen saturation, and assessing for signs of hypoxemia or respiratory distress. Airway and breathing take precedence in line with the ABCs of emergency care: Airway, Breathing, Circulation.

Complications such as airway obstruction from the tongue, laryngospasm, or aspiration, as well as hypoventilation due to residual anesthetics, are common in the immediate postoperative period. If respiratory compromise is not addressed promptly, it can lead to hypoxia, cardiac arrest, or death.

Monitoring respiratory status is like checking the fuel and engine in a car before starting a road trip. If the car (patient) can’t run (breathe properly), nothing else matters until this is resolved.

Nurse Mia should take the following steps when evaluating the client’s respiratory status:

• Ensure the airway is clear by observing for obstruction, auscultating breath sounds, and confirming effective airflow.
• Monitor oxygen saturation levels using pulse oximetry and apply supplemental oxygen if needed.
• Assess for signs of hypoxemia, such as cyanosis, restlessness, or changes in mental status.
• Check respiratory rate and pattern for adequacy of ventilation, and observe for accessory muscle use or shallow breathing.
• Collaborate with the anesthesia provider if the client shows signs of airway compromise or inadequate oxygenation.

✘Incorrect answer options:

The client’s level of consciousness. While assessing the level of consciousness is important, it is a secondary priority after confirming airway patency and respiratory function. Changes in consciousness may occur due to hypoxia, making respiratory assessment the first step.

The client’s current level of pain. Pain assessment is important for comfort and recovery, but it is not the first priority in the PACU. Pain should be addressed after ensuring that airway, breathing, and circulation are stable.

The reflexes and movement in the client’s extremities. Assessing extremity reflexes and movement is typically done during a neurological or musculoskeletal evaluation, which is not a high priority in the immediate postoperative period unless the surgery involved the spine or peripheral nerves. Respiratory and cardiovascular stability must be established first.

EXPLANATION

✔Correct answer:

Listen to the lungs to check for crackles. Delegating lung sound auscultation to an experienced LPN is appropriate because this task falls within the LPN’s scope of practice. LPNs are trained to perform focused assessments, such as listening to lung sounds and identifying abnormal findings like crackles. However, it is the RN’s responsibility to interpret these findings in the context of the patient’s overall clinical condition, evaluate their significance, and take appropriate action. By delegating this task, Nurse Olivia can focus on higher-level responsibilities, such as evaluating the patient’s pain and monitoring for complications.

When delegating tasks, it is crucial to ensure that the delegated task matches the LPN’s competency level and the needs of the patient. Tasks that require advanced assessment, clinical judgment, or decision-making (e.g., interpreting abnormal findings or evaluating complex symptoms) must remain with the RN.

Delegating lung sound auscultation to an LPN is like asking a skilled technician to gather data (e.g., measurements or readings). While the technician provides the information, the engineer (RN) analyzes it to make informed decisions about the project.

Nurse Olivia should provide clear instructions and follow-up to ensure effective delegation. Key considerations include:

• Instruct the LPN to auscultate lung sounds and report abnormal findings, such as crackles, wheezes, or diminished breath sounds.
• Review the LPN’s report of findings and use that data to guide patient care decisions.
• Reassess the patient as needed, particularly if the LPN reports concerning findings or changes in the patient’s condition.
• Document findings and interventions promptly and accurately in the patient’s record.

✘Incorrect answer options:

Evaluate the patient’s reports of chest pain. Evaluating chest pain involves advanced clinical judgment, as the RN must determine the severity, characteristics, and potential causes of the pain. This task cannot be delegated to an LPN, as it requires critical thinking and decision-making.

Monitor lab results for indicators of oxygenation changes. Interpreting lab results, such as arterial blood gases (ABGs) or D-dimer levels, requires professional judgment and falls within the scope of the RN. While LPNs may collect and review lab results, the RN is responsible for interpreting their significance and deciding on interventions.

Assess for clinical signs of respiratory failure. Assessing for respiratory failure requires advanced knowledge and the ability to synthesize clinical data, such as respiratory rate, oxygen saturation, mental status, and ABG results. This task must be performed by the RN, as it involves identifying life-threatening conditions and initiating appropriate interventions.