Friday, September 2, 2016

Nursing Prioritization, Delegation and Assignment 1 (20 Items)

Questions about prioritization and delegation in the NCLEX are some of the most difficult for students to answer. These kind of questions requires nursing students to use their different levels of analysis and testing their critical thinking. The best way to prepare for these kind of questions is to practice them. Good thing we have 20 nursing questions about prioritization, delegation and assignment.
The inability to delegate is one of the biggest problems I see with managers at all levels.
 —Eli Broad


Included topics in this exam are:
  • Prioritization
  • Delegation and Assignment


Follow the guidelines below to make the most out of this exam:
  • Read each question carefully and choose the best answer.
  • You are given one minute per question. Spend your time wisely!
  • Answers and rationales are given below. Be sure to read them.
  • If you need more clarifications, please direct them to the comments section.
 Nursing Prioritization, Delegation and Assignment 1 (20 Items)
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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?
A. Perform postural drainage and chest physiotherapy every 4 hours
B. Allow the patient to decide whether she needs aerosolized medications
C. Place the patient in a private room to decrease the risk of further infection
D. 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.
A. Use a lift sheet when moving and positioning the patient in bed
B. Use an electric razor when shaving the patient each day
C. Use a soft-bristled toothbrush or tooth sponge for oral care
D. Use a rectal thermometer to obtain a more accurate body temperature
E. 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?
A. Perform endotracheal intubation and initiate mechanical ventilation
B. Immediately begin continuous positive airway pressure (CPAP) via the patient’s nose and mouth
C. Administer furosemide (Lasix) 100 mg IV push stat
D. 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)?
A. Assisting the patient to sit up on the side of the bed
B. Instructing the patient to cough effectively
C. Teaching the patient to use incentive spirometry
D. 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)?
A. Discuss weight-loss strategies such as diet and exercise with the patient
B. Teach the patient how to set up the BiPAP machine before sleeping
C. Remind the patient to sleep on his side instead of his back.
D. Administer modafinil (Provigil) to promote daytime wakefulness

6. After change of shift, you are assigned to care for the following patients. Which patient should you assess first?
A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab
B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation
C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics
D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator

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?
A. Heart rate of 98 beats/min
B. Respiratory rate of 24 breaths/min
C. Blood pressure of 168/90 mm Hg
D. 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.
A. Auscultate breath sounds
B. Administer medications via metered-dose inhaler (MDI)
C. Complete in-depth admission assessment
D. Initiate the nursing care plan
E. 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?
A. A 58-year old on airborne precautions for tuberculosis (TB)
B. A 68-year old just returned from bronchoscopy and biopsy
C. A 72-year old who needs teaching about the use of incentive spirometry
D. 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?
A. Reassure the patient that the ventilator will do the work of breathing for him
B. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm
C. Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning
D. 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?
A. Suggest that the patient’s oxygen be humidified
B. Suggest that a simple face mask be used instead of a nasal cannula.
C. Suggest that the patient be provided with an extra pillow
D. 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?
A. Observe how well the patient performs pursed-lip breathing
B. Plan a nursing care regimen that gradually increases activity intolerance
C. Assist the patient with basic activities of daily living
D. Consult with the physical therapy department about reconditioning exercises

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?
A. Blood pressure of 152/84 mm Hg
B. Respiratory rate of 27 breaths/min
C. Heart rate of 92 beats/min
D. 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?
A. Theophylline (Theolair, Theochron)
B. Surfactant (Exosurf)
C. Dexamethasone (Decadron)
D. Albuterol (Proventil)

15. When a patient with TB is being prepared for discharge, which statement by the patient indicates the need for further teaching?
A. “Everyone in my family needs to go and see the doctor for TB testing.”
B. “I will continue to take my isoniazid until I am feeling completely well.”
C. “I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag.”
D. “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?
A. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes
B. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs
C. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation
D. Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status.

17. Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team?
A. Evaluating the patient’s complaint of chest pain
B. Monitoring laboratory values for changes in oxygenation
C. Assessing for symptoms of respiratory failure
D. 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?
A. Warfarin (Coumadin) 1.0 mg by mouth (PO)
B. Morphine sulfate 2 to 4 mg IV
C. Cephalexin (Keflex) 250 mg PO
D. 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.
A. Remove the inhaler cap and shake the inhaler
B. Open your mouth and place the mouthpiece 1 to 2 inches away
C. Tilt your head back and breathe out fully
D. Hold your breath for at least 10 seconds
E. Press down firmly on the canister and breathe deeply through your mouth
F. 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. 
A. A 38-year old with moderate persistent asthma awaiting discharge
B. A 63-year old with a tracheostomy needing tracheostomy care every shift.
C. A 56-year old with lung cancer who has just undergone left lower lobectomy
D. A 49-year old just admitted with a new diagnosis of esophageal cancer.

Answers and Rationale

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.

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