Nursing Management, Delegation and Prioritization

1. A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient’s care?

1. Perform postural drainage and chest physiotherapy every 4 hours
2. Allow the patient to decide whether she needs aerosolized medications
3. Place the patient in a private room to decrease the risk of further infection
4. Plan activities to allow at least 8 hours of uninterrupted sleep

2. A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply.

1. Use a lift sheet when moving and positioning the patient in bed
2. Use an electric razor when shaving the patient each day
3. Use a soft-bristled toothbrush or tooth sponge for oral care
4. Use a rectal thermometer to obtain a more accurate body temperature
5. Be sure the patient’s footwear has a firm sole when the patient ambulates

3. A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient’s care, you would anticipate a physician order for what action?

1. Perform endotracheal intubation and initiate mechanical ventilation
2. Immediately begin continuous positive airway pressure (CPAP) via the patient’s nose and mouth
3. Administer furosemide (Lasix) 100 mg IV push stat
4. Call a code for respiratory arrest

4. A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (PCT)?

1. Assisting the patient to sit up on the side of the bed
2. Instructing the patient to cough effectively
3. Teaching the patient to use incentive spirometry
4. Auscultation of breath sounds every 4 hours

5. A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant (PCT)?

1. Discuss weight-loss strategies such as diet and exercise with the patient
2. Teach the patient how to set up the BiPAP machine before sleeping
3. Remind the patient to sleep on his side instead of his back.
4. Administer modafinil (Provigil) to promote daytime wakefulness

6. After change of shift, you are assigned to care for the following patients. Which patient should you assess first?

1. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab
2. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation
3. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics
4. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator

7. After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the RN immediately?

1. Heart rate of 98 beats/min
2. Respiratory rate of 24 breaths/min
3. Blood pressure of 168/90 mm Hg
4. Tympanic temperature of 101.4 F (38.6 C)

8. An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply.

1. Auscultate breath sounds
2. Administer medications via metered-dose inhaler (MDI)
3. Complete in-depth admission assessment
4. Initiate the nursing care plan
5. Evaluate the patient’s technique for using MDI’s

9. The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit?

1. A 58-year old on airborne precautions for tuberculosis (TB)
2. A 68-year old just returned from bronchoscopy and biopsy
3. A 72-year old who needs teaching about the use of incentive spirometry
4. A 69-year old with COPD who is ventilator dependent

10. The high-pressure alarm on a patient’s ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next?

1. Reassure the patient that the ventilator will do the work of breathing for him
2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm
3. Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning
4. Insert an oral airway to prevent the patient from biting on the endotracheal tube

11. The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient’s comfort for this problem?

1. Suggest that the patient’s oxygen be humidified
2. Suggest that a simple face mask be used instead of a nasal cannula.
3. Suggest that the patient be provided with an extra pillow
4. Suggest that the patient sit up in a chair at the bedside

12. The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision?

1. Observe how well the patient performs pursed-lip breathing
2. Plan a nursing care regimen that gradually increases activity intolerance
3. Assist the patient with basic activities of daily living
4. Consult with the physical therapy department about reconditioning exercises

13. The patient with COPD tells the nursing assistant that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the nursing assistant to report which of these?

1. Blood pressure of 152/84 mm Hg
2. Respiratory rate of 27 breaths/min
3. Heart rate of 92 beats/min
4. Oral temperature of 101.2 F (38.4C)

14. To improve respiratory status, which medication should you be prepared to administer to the newborn infant with RDS?

1. Theophylline (Theolair, Theochron)
2. Surfactant (Exosurf)
3. Dexamethasone (Decadron)
4. Albuterol (Proventil)

15. When a patient with TB is being prepared for discharge, which statement by the patient indicates the need for further teaching?

1. “Everyone in my family needs to go and see the doctor for TB testing.”
2. “I will continue to take my isoniazid until I am feeling completely well.”
3.  “I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag.”
4.  “I will change my diet to include more foods rich in iron, protein, and vitamin C.”

16. 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?

1. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes
2. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs
3. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation
4. Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status.

17. Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team?

1. Evaluating the patient’s complaint of chest pain
2. Monitoring laboratory values for changes in oxygenation
3. Assessing for symptoms of respiratory failure
4. Auscultating the lungs for crackles

18. Which of these medication orders for a patient with a pulmonary embolism is more important to clarify with the prescribing physician before administration?

1. Warfarin (Coumadin) 1.0 mg by mouth (PO)
2. Morphine sulfate 2 to 4 mg IV
3. Cephalexin (Keflex) 250 mg PO
4. Heparin infusion at 900 units/hr

19. You are a team leader RN working with a student nurse. The student nurse is to teach a patient how to use and MDI without a spacer. Put in correct order the steps that the student nurse should teach the patient.

1. Remove the inhaler cap and shake the inhaler
2. Open your mouth and place the mouthpiece 1 to 2 inches away
3. Tilt your head back and breathe out fully
4. Hold your breath for at least 10 seconds
5. Press down firmly on the canister and breathe deeply through your mouth
6. Wait at least 1 minute between puffs.

20. You are acting as preceptor for a newly graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide care to which patients? Select all that apply.

1. A 38-year old with moderate persistent asthma awaiting discharge
2. A 63-year old with a tracheostomy needing tracheostomy care every shift.
3. A 56-year old with lung cancer who has just undergone left lower lobectomy
4. A 49-year old just admitted with a new diagnosis of esophageal cancer.

21. Jenna is a nurse from the medical-surgical unit of a tertiary hospital. She was asked to float on the orthopedic in which she has no prior experience on working on. Which client should be assigned to her?

1. A client with a cast for a fractured femur and who has numbness and discoloration of the toes.
2. A client with balanced skeletal traction and needs assistance with morning care.
3. A client who had an above-the-knee amputation yesterday and has currently has a temperature of 101.4ºF.
4. A client who had a total hip replacement two days ago and needs blood glucose monitoring.

22. Sally is a nurse working in an emergency department and receives a client after a radiological incident. Which task is utmost priority for the nurse to do first?

1. Decontaminate the client’s clothing.
2. Decontaminate the open wound on the client’s thigh.
3. Decontaminate the examination room the client is placed in.
4. Save the client’s vomitus for analysis by the radiation safety staff.

23. The nurse plans care for a client in the post anesthesia care unit. The nurse should assess first the client’s:

1. respiratory status.
2. level of consciousness.
3. level of pain.
4. reflexes and movement of extremities.

24. Nurse Jackie is reviewing the diet of a 28-year-old female who reports several months of intermittent abdominal pain, abdominal bloating, and flatulence. The nurse should tell the client to avoid:

1. fiber.
2. broccoli.
3. yogurt.
4. simple carbohydrates.

25. Nurse Jason is planning care for a client who will undergo a colposcopy. Which of the following actions should Jason take first?

1. Discuss the client’s fear regarding potential cervical cancer.
2. Assist with silver nitrate application to the cervix to control bleeding.
3. Give instructions regarding douching and sexual relations.
4. Administer pain medications.

26. Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first?

1. A client with diabetes being discharged today.
2. A 35-year-old male with tracheostomy and copious secretions.
3. A teenager scheduled for physical therapy this morning.
4. A 78-year-old female client with pressure ulcer that needs dressing change.

27. Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first?

1. Call for help to get the client back in bed.
2. Establish whether the client is responsive.
3. Assist the client back to bed.
4. Ask the client what happened.

28. Paige is a nurse preceptor who is working with a new nurse Joyce. She notes that the Joyce is reluctant to delegate tasks to members of the care team. Paige recognizes that this reluctance is mostly likely due to:

1. Role modeling behaviors of the preceptor.
2. The philosophy of the new nurse’s school of nursing.
3. The orientation provided to the new nurse.
4. Lack of trust to the members of the healthcare team.

29. Nurse Paul is developing a care plan for a client after bariatric surgery for morbid obesity. The nurse should include which of the following on the care plan as the priority complication to prevent:

1. pain.
2. wound infection.
3. depression.
4. thrombophlebitis.

30. 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?

1. Administer pain medications.
2. Administer IV fluids.
3. Administer dopamine.
4. Administer oxygen via nasal cannula.

31. Nurse Pietro receives a 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?

1. Call for a social worker to meet with the family.
2. Check the child’s blood pressure, pulse, respiration, and temperature.
3. Administer pain medications.
4. Speak with the parents about how the fracture occurred.

32. Nurse Skye is on the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?

1. A client scheduled for cardiac ultrasound this morning.
2. A client with syncope being discharged today.
3. A client with chronic bronchitis on nasal oxygen.
4. A client with diabetic foot ulcer that needs a dressing change.

33. 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?

1. Determine the level of consciousness.
2. Push the call button for help.
3. Turn the client face up to assess.
4. Go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician.

34. Nurse Adonai is working on the night shift with a nursing assistant. The nursing assistant comes to the nurse stating that the other nurse working on the unit is not assessing a client with abdominal pain despite multiple requests. Which of the following actions by the nurse is best?

1. Ask the other nurse if she needs help.
2. Assess the client and let the other nurse know what should be done.
3. Ask the client if he is satisfied with his care.
4. Contact the nursing supervisor to address the situation.

35. Nurse Vivian is reviewing immunizations with the caregiver of a 72-year-old client with a history of cerebrovascular disease. The caregiver learns that which immunization is a priority for the client?

1. Hepatitis A vaccine.
2. Lyme’s disease vaccine.
3. Hepatitis B vaccine.
4. Pneumococcal vaccine.

36. 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?

1. The patient was recently in a motor vehicle accident
2. The patient participated in an aerobic exercise program for 6 months
3. The patient gave birth to her youngest child 1 year ago
4. The patient was on bed rest for 6 hours after a diagnostic procedure

37. You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced nursing assistant?

1. Assessing the patient’s respiratory status every 4 hours
2. Taking vital signs and pulse oximetry readings every 4 hours
3. Checking the ventilator settings to make sure they are as prescribed
4. Observing whether the patient’s tube needs suctioning every 2 hours

38. 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?

1. Administer ordered antibiotics as scheduled
2. Hyperoxygenate the patient before suctioning
3. Maintain the head of the bed at a 30 – to 45-degree angle
4. Suction the airway when coarse crackles are audible

39. 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?

1. The patient has fine bibasilar crackles
2. The patient’s respiratory rate is 8 breaths/min.
3. The patient sits up and leans over the night table.
4. The patient has a large barrel chest.

40. You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to a nursing assistant?

1. Teaching the patient about the importance of adequate of fluid intake and hydration.
2. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed
3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake
4. Encouraging the patient to take a deep breath, hold it for 2 seconds, then cough two or three times in succession.

41. 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?

1. The patient says that her right leg aches all night
2. The right calf is warm to the touch and is larger than the left calf
3. The patient is unable to remember her husband’s first name
4. There are multiple ecchymotic areas on the patient’s arms

42. 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)

1. Avoid potential environmental asthma triggers such as smoke
2. Use the inhaler 30 minutes before exercising to prevent bronchospasm
3. Wash all bedding in cold water to reduce and destroy dust mites.
4. Be sure to get at least 8 hours of rest and sleep every night.
5. Avoid foods prepared with monosodium glutamate (MSG)

43. You are providing nursing care for a newborn infant with respiratory distress syndrome (RDS) who is receiving nasal CPAP ventilation. What complications should you monitor for this infant?

1. Pulmonary embolus
2. Bronchitis
3. Pneumothorax
4. Pneumonia

44. 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?

1. Instructing the patient to alternate rest and activity periods
2. Encouraging, monitoring, and recording nutritional intake
3. Monitoring cardiorespiratory response to activity
4. Planning activities for periods when the patient has the most energy

45. 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?

1. Chest tube drainage of 10 to 15 mL/hr
2. Continuous bubbling in the water seal chamber
3. Complaints of pain at the chest tube site
4. Chest tube dressing dated yesterday

46. You are supervising a student nurse who is performing tracheostomy care for a patient. For which action by the student should you intervene?

1. Suctioning the tracheostomy tube before performing tracheostomy care
2. Removing old dressings and cleaning off excess secretions
3. Removing the inner cannula and cleaning using universal precautions
4. Replacing the inner cannula and cleaning the stoma site.
5. Changing the soiled tracheostomy ties and securing the tube in place

47. 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)

1. Position the patient supine and turned on his side
2. Apply direct lateral pressure to the nose for 5 minutes
3. Maintain universal body substances precautions.
4. Apply ice or cool compresses to the nose
5. Instruct the patient not to blow the nose for several hours.

48. 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?

1. Assessing for bilateral breath sounds and symmetrical chest movements
2. Auscultating over the stomach to rule out esophageal intubation
3. Marking the tube 1 cm from where it touches the incisor tooth or nares
4. Ordering a chest radiograph to verify that tube placement is correct

49. 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?

1. The patient starts crying and says she can’t go on with treatment much longer
2. The patient complains of sharp, stabbing chest pain with every deep breath
3. The patient’s blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min
4. The patient’s dressing at the thoracentesis site has 1 cm of bloody drainage

50. 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?

1. Frequent swallowing
2. Hypotonic bowel sounds
3. Complaints of a sore throat
4. Heart rate of 112 beats/min

Answers and Rationales

1. Answer: A. Perform postural drainage and chest physiotherapy every 4 hours. Airway clearance techniques are critical for patients with cystic fibrosis and should take priority over the other activities. Although allowing more independent decision making is important for adolescents, the physiologic need for improved respiratory function takes precedence at this time. A private room may be desirable for the patient but is not necessary. With increased shortness of breath, it will be more important that the patient have frequent respiratory treatments than 8 hours of sleep.
2. Answers: A, B, C, and E. While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). All of the other instructions are appropriate to the care of a patient receiving anticoagulants.
3. Answer: A. Perform endotracheal intubation and initiate mechanical ventilation. A non-rebreather mask can deliver nearly 100% oxygen. When the patient’s oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient’s work of breathing.
4. Answer: A. Assisting the patient to sit up on the side of the bed. Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of a nursing assistant. Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate for a licensed nurse.
5. Answer: C. Remind the patient to sleep on his side instead of his back. The nursing assistant can remind patients about actions that have already been taught by the nurse and are part of the patient’s plan of care. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can delegate administration of medication to an LPN/LVN.
6. Answer: D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator. The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient’s needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations are urgent. in COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable.
7. Answer: D. Tympanic temperature of 101.4 F (38.6 C). Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body’s normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the respiratory system.
8. Answers: A and B. The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN. Independently completing the admission assessment, initiating the nursing care plan, and evaluating a patient’s abilities require additional education and skills. These actions are within the scope of practice of the professional RN.
9. Answer: C. A 72-year old who needs teaching about the use of incentive spirometry. Many surgical patients are taught about coughing, deep breathing, and use of incentive spirometry preoperatively. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.
10. Answer: B. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. Manual ventilation of the patient will allow you to deliver an FiO2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, and/or insertion of an oral airway, but the first step should be assessment of the reason for the high-pressure alarm and resolution of the hypoxemia.
11. Answer: A. Suggest that the patient’s oxygen be humidified. When the oxygen flow rate is higher than 4 L/min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Application of a water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.
12. Answer: A. Observe how well the patient performs pursed-lip breathing.Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to a nursing assistant. Planning and consulting require additional education and skills, appropriate to an RN.
13. Answer: D. Oral temperature of 101.2 F (38.4C). A patient who did not have the pneumonia vaccination or flu shot is at increased risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection, which may be respiratory in origin. All of the other vital sign values are slightly elevated but are not a cause for immediate concern.
14. Answer: B. Surfactant (Exosurf). Exosurf neonatal is a form of synthetic surfactant. An infant with RDS may be given two to four doses during the first 24 to 48 hours after birth. It improves respiratory status, and research has show a significant decrease in the incidence of pneumothorax when it is administered.
15. Answer: B. “I will continue to take my isoniazid until I am feeling completely well.” Patients taking isoniazid must continue the drug for 6 months. The other 3 statements are accurate and indicate understanding of TB. Family members should be tested because of their repeated exposure to the patient. Covering the nose and mouth when sneezing or coughing, and placing the tissues in plastic bags help prevent transmission of the causative organism. The dietary changes are recommended for patients with TB.
16. Answer: D. Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status. The patient’s history and symptoms suggest the development of ARDS, which will require intubation and mechanical ventilation. The maximum oxygen delivery with a nasal cannula is an Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.
17. Answer: D. Auscultating the lungs for crackles. An LPN who has been trained to auscultate lungs sounds can gather data by routine assessment and observation, under supervision of an RN. Independently evaluating patients, assessing for symptoms of respiratory failure, and monitoring and interpreting laboratory values require additional education and skill, appropriate to the scope of practice of the RN.
18. Answer: A. Warfarin (Coumadin) 1.0 mg by mouth (PO). Medication safety guidelines indicate that use of a trailing zero is not appropriate when writing medication orders because the order can easily be mistaken for a larger dose, such as 10 mg. The order should be clarified before administration. The other orders are appropriate, based on the patient’s diagnosis.
19. Answer: A, C, B, E, D, F. Before each use, the cap is removed and the inhaler is shaken according to the instructions in the package insert. Next the patient should tilt the head back and breathe out completely. As the patient begins to breathe in deeply through the mouth, the canister should be pressed down to release one puff (dose) of the medication. The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs. The patient should wait for at least 1 minute between puffs from the inhaler.
20. Answers. A and B. The new RN is at an early point in her orientation. The most appropriate patients to assign to her are those in stable condition who require routine care. The patient with the lobectomy will require the care of a more experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. As the new nurse advances through her orientation, you will want to work with her in providing care for these patients with more complex needs.
21. Answer: D. A client who had a total hip replacement two days ago and needs blood glucose monitoring. A nurse from the medical-surgical floor floated to the orthopedic unit should be given clients with stable condition as those have care similar to her training and experience. A client who is in postoperative state is more likely to be on a stable condition.
22. Answer: B. Decontaminate the open wound on the client’s thigh. Decontaminating an open wound is the first priority for the client. This minimizes absorption of radiation in the client’s body.
23. Answer: A. respiratory status. Assessing respiratory status is the first priority. Remember ABC.
24. Answer: B. Broccoli. Broccoli are gas forming and therefore, should be avoided.
25. Answer: B. Assist with silver nitrate application to the cervix to control bleeding. The priority nursing action when caring for a client who underwent colposcopy is to assist in controlling potential bleeding by applying silver nitrate to the cervix.
26. Answer: C. A 35-year-old male with tracheostomy and copious secretions. The patient with problem of the airway should be given highest priority. Remember Airway, Breathing, and Circulation (ABC) is a priority.
27. Answer: B. Establish whether the client is responsive. Assess first for responsiveness.
28. Answer: D. Lack of trust to the members of the healthcare team. Lack of trust is the common reason for reluctance in delegation of tasks.
29. Answer: B. wound infection. Wound infection is the most common complication among obese clients who had undergone surgery. This is due to their poor blood supply in their adipose tissues.
30. Answer: D. Administer oxygen via nasal cannula. Promotion of adequate oxygenation is the most vital to life and therefore should be given highest priority by the nurse.
31. Answer: D. Speak with the parents about how the fracture occurred. In case of injury, especially among children, it is very important that the nurse should first assess possible abuse. Abuse is one of the reporting responsibilities of the nurse.
32. Answer: C. A client with chronic bronchitis on nasal oxygen. A client with airway problems should be attended first.
33. Answer: A. Determine the level of consciousness. Assessing the level of consciousness should be the first action when dealing with clients that might have fell over.
34. Answer: D. Contact the nursing supervisor to address the situation. The nurse should use proper channel of communication. The nursing supervisor is responsible for the actions of the different members of the nursing team.
35. Answer: D. Pneumococcal vaccine. Pneumococcal vaccine is a priority immunization amongst elderly especially those with chronic illnesses. It is administered every five (5) years.
36. Answer: A. The patient was recently in a motor vehicle accident. 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.
37. Answer: B. Taking vital signs and pulse oximetry readings every 4 hours. 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
38. Answer: C. Maintain the head of the bed at a 30 – to 45-degree angle. 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
39. Answer: B. The patient’s respiratory rate is 8 breaths/min. 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
40. Answer: C. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake. 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
41. Answer: C. The patient is unable to remember her husband’s first name. 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.
42. Answer: A, B, D, and E. 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.
43. Answer: C. Pneumothorax. 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
44. Answer: B. Encouraging, monitoring, and recording nutritional intake. 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
45. Answer: B. Continuous bubbling in the water seal chamber. 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.
46. Answer: C. Removing the inner cannula and cleaning using universal precautions. 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.
47. Answers: B, C, D, and E. 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
48. Answer: C. Marking the tube 1 cm from where it touches the incisor tooth or nares. 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.
49. Answer: C. The patient’s blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min. 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
50. Answer: A. Frequent swallowing. 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.