PASS_Delegation/Prioritization Quiz
24. Which task is appropriate to delegate to the experienced nursing assistant who is assisting the RN in caring for a head-injured patient who is receiving mechanical ventilation? a. Maintain the head in a midline neutral position. b. Calculate the cerebral perfusion pressure. c. Suction the patient as needed. d. Monitor for respiratory distress.
a
14. A registered nurse from the postpartum unit is assigned to care for clients on the oncology unit for an absent nurse. Which of the following assignments is MOST appropriate for the postpartum unit nurse? a. A 60-year-old man after a routine prostatectomy. b. A 40-year-old woman diagnosed with ovarian cancer receiving IV chemotherapy. c. A 30-year-old woman with breast biopsy for cancer scheduled for surgery that day. d. A 50-year-old man diagnosed with bone cancer and severe pain.
a
15. The nurse checks on her client who was admitted to the hospital with pneumonia. He has been coughing profusely and has required nasotracheal suctioning. He has an IV infusion of antibiotics. He is febrile. The client asks the nurse if he can have a bath because he has been perspiring profusely. The most appropriate task for the nurse to delegate to the nursing assistant a. Administering a bed bath. b. Obtaining vital signs. c. Nasotracheal suctioning. d. Changing IV dressing.
a
16. Which task is most appropriate for an RN to delegate to the LPN? a. Changing the client's sterile abdominal dressing prior to the CT scan. b. Obtaining vital signs on a client who is having an abdominal CT scan later in the morning. c. Hanging the intravenous solution that is to be started before the client's CT scan. d. Explaining to the client about the preparation for an abdominal CT scan.
a
19. Which of these patients with diabetes should the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit? A patient: a. who needs blood glucose monitoring and insulin before each meal. b. with sensory neuropathy who needs teaching about foot care. c. with diabetic ketoacidosis who has an IV running at 250 mL/hr. d. who was admitted with fatigue and shortness of breath.
a
20. The nurse manager in a home health agency is making patient assignments for the day. Which patient should be assigned to an experienced LPN/LVN? A patient a. needs assistance in checking blood glucose levels and administering insulin after a left foot amputation. b. needs an intake assessment after discharge from the hospital with an open reduction and internal fixation of a hip fracture c. is receiving IV antibiotics at home for a diagnosis of osteomyelitis associated with a compound fracture. d. has an ankle cast and called the agency this morning complaining about an unpleasant smell coming from the cast.
a
27. Which of these nursing actions could the RN on the orthopedic unit delegate to a nursing assistant? a. Check the vital signs for a patient who was admitted after a total knee replacement 3 hours ago. b. Teach a patient with a right ankle fracture how to use crutches when transferring and ambulating. c. Remove the wound drain for a patient who had an open reduction of a hip fracture 3 days ago. d. Assess for bruising on a patient who is receiving warfarin (Coumadin) to prevent deep vein thrombosis.
a
28. Which of these nursing actions can the home health nurse delegate to a home health aide who is making daily visits to a patient with newly diagnosed type 2 diabetes? a. Clean the patient's feet, and apply moisturizing lotion. b. Assist the patient's spouse in choosing appropriate dietary items. c. Inspect the extremities for evidence of poor circulation. d. Evaluate the patient's use of a home blood glucose monitor.
a
29. A patient is admitted to the intensive care unit with multiple rib fractures, pelvic fractures, and bilateral long bone fractures. Which physician request should the RN implement first? a. Give oxygen at 4 to 6 L/min to keep O2 saturation at 93%. b. Give 5% dextrose in 0.45% normal saline at 125 mL/hr. c. Give cefazolin (Kefzol) 500 mg IV now and every 6 hours. d. Type and crossmatch for 4 units of packed red blood cells.
a
31. A patient with type 2 diabetes who is taking metformin (Glucophage) is seen in the diabetic clinic. The fasting blood glucose is 108 mg/dL, and the glycosylated hemoglobin (HbA1c) is 8.2%. Which action will the nurse plan to take next? a. Ask the patient about current dietary intake and medication use. b. Instruct the patient to continue with the current diet and Glucophage use. c. Talk about the possibility of adding rapid-acting insulin to the regimen. d. Discuss the need to check blood glucose several times every day.
a
4. Which of these patients who have just arrived in the emergency department should the nurse classify as emergent and needing medical evaluation immediately? a. The 70-year-old with hypertension whose right leg is pulseless, pale and cold to touch. b. The 69-year-old with a 20 year history of diabetes complaining of numbness of both feet. c. The 64-year-old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C). d. The 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness.
a
6. A patient with pneumonia has a physician's prescription stating "Adjust oxygen to keep the SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN? a. Adjust the position of the oxygen tubing. b. Choose which O2 delivery device to use for the patient. c. Change the O2 flow rate to keep the SpO2 as prescribed. d. Assess for signs and symptoms of hypoventilation.
a
8. The nurse needs to complete all of the following tasks. Which task does the nurse complete first? a. Notify the health care provider of the decreased level of consciousness in the client who had a stroke yesterday b. Do the teaching on wound care for a client with a wound drain who is being discharged later today. c. Make a referral to the home care nurse for a client who is being discharged in 2 days. d. Cough and deep breathe the client who had surgery yesterday.
a
9. The charge nurse on a surgical unit is doing staff assignments for the 3 to 11 shift. Which client should be assigned to the LPN? The client who: a. had a vaginal hysterectomy 2 days ago. b. had a mastectomy this morning. c. had a total laryngectomy yesterday. d. is being discharged this evening following total colectomy
a
1. Which of these patients should the nurse assess first? a. The patient admitted with hypertensive crisis who has a nitroprusside (Nipride) drip and BP of 149/80. b. The patient who had percutaneous transluminal angioplasty (PTCA) of the right femoral artery 30 minutes ago. c. The patient who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot. d. The patient with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid.
b
11. An elderly patient recovering from a hip replacement is being transferred from the hospital to a skilled nursing facility (SNF). The SNF nurse should assign the patient to which of the following staff members? a. An LPN/LVN with 10 years of experience in home health care. b. An RN who has been practicing for 6 months in an acute-care setting. c. A nursing assistant who has 5 years of experience in a skilled nursing facility. d. A certified nursing assistant with 20 years of experience on an orthopedic postoperative unit.
b
18. Which patient should the nurse assess first? The patient taking: a. pioglitazone (Actos) who has bilateral ankle swelling. b. chlorpropamide (Diabinese) who is dizzy and sweaty. c repaglinide (Prandin) who has nausea and back pain. d. metformin (Glucophage) who has abdominal cramps.
b
22. The charge nurse for the neurosurgical unit is making assignments for a nurse who floated from the pediatric unit. Which patient should be assigned to the float nurse? A Patient: a. with an arteriovenous malformation who is complaining of a headache. b. who had a carotid endarterectomy and needs neurologic and vital sign monitoring. c. who has possible intracerebral hemorrhage and is awaiting testing for brain activity. d. with an acute ischemic stroke who is receiving IV thrombolytic therapy.
b
25. These four patients are admitted to the emergency department (ED) after a multiple vehicle accident. Which patient should be assigned to the RN who just completed orientation to the ED after working on the orthopedic unit for a year? a. A patient who was riding on a motorcycle and was thrown 20 feet. b. A back seat passenger who complains of severe wrist and arm pain. c. An alert passenger with a respiratory rate of 38 who says, "I'm fine!" d. An unconscious vehicle driver who was not wearing a seat belt.
b
26. Which patient should the nurse assess first after taking change-of-shift report? The patient with: a. breast cancer and several metastatic brain tumors who is receiving intensive chemotherapy. b. a closed head injury who is lethargic and has had a Glasgow Coma Scale score decrease from 14 to 12. c. a traumatic brain injury whose Glasgow Coma Scale score has been 5 since admission yesterday. d. a transient ischemic attack who needs preoperative teaching about a carotid endarterectomy.
b
3. The nurse assesses an elderly patient receiving total parenteral nutrition (TPN). The nurse is most concerned if which of the following is observed? a. The patient's serum albumin is 3.2 g/dL. b. The patient's urinary output is 250 mL per hour. c. Fine crackles are heard during auscultation of the posterior bases of both lungs. d. The patient's oral temperature is 100.2°F
b
10. The nurse cares for clients on an acute care unit. After making client rounds, the nurse should FIRST administer which medication? a. Nitroglycerin patch to a client with a history of chest pain during physical activity. b. Captopril (Vasotec) to a client diagnosed with heart failure with 1 + pretibial edema. c. Morphine sulfate to a client diagnosed with a myocardial infarction reporting chest pain. d. Nifedipine (Procardia) to a client with a blood pressure of 158/92.
c
2. The client with pneumonia is receiving oxygen for hypoxia. The client tells the nurse that the sensation of air hunger is worse. What is the nurse's first action? a. Attempt to calm the client using guided imagery. b. Document the observation as the only action. c. Increase the oxygen flow rate. d. Notify the physician.
c
23. A 70-year-old who was admitted with atrial fibrillation suddenly develops right-sided weakness. The patient is unable to respond to questions and has a heart rate of 98, respirations 22, BP 136/70, and O2 saturation 99%. Which action should the nurse take next? a. Document the current patient assessment findings. b. Administer oxygen at 4 L/min per nasal cannula. c. Notify the patient's physician of the change in status. d. Give the patient's scheduled subcutaneous heparin.
c
30. A patient is admitted to the emergency department after a motorcycle accident with a compound fracture of the left femur. Which action should the nurse take first? a. Administer the prescribed analgesic. b. Immobilize the left leg with a splint. c. Check the dorsalis pedis pulses. d. Place a dressing on the affected area.
c
5. A patient who is 2 days post MI is ambulating in the hallway on the coronary step-down unit and suddenly tells the nurse, "I feel really dizzy." Which action should the nurse take first? a. Take the patient's blood pressure. b. Check the patient's apical pulse. c. Help the patient to sit down. d. Notify the physician immediately.
c
7. All of these patient assignments have been made by the charge nurse. Which assignment should the nurse question? a. The RN with 8 years of experience caring for a patient with PVD and a total cholesterol of 390. b. The RN with 3 years of experience caring for a patient with a pulmonary embolism who is on continuous IV heparin. c. The LPN/LVN with 20 years of experience caring for a patient with a headache whose blood pressure is 210/120. d. The LPN/LVN with 5 years of experience caring for a patient with leg ulcers who is awaiting SNF placement.
c
12. Which of the following phone calls should the home health nurse return FIRST? a. A 45-year-old client reporting leg pain after walking two blocks to the grocery store. b. A 66-year-old client experiences increased pain when coughing after a bilateral hernia repair. c. A 60-year-old client diagnosed with rheumatoid arthritis experiences cold hands and feet during cold weather. d. A 50-year-old client diagnosed with essential hypertension reports pain between the shoulder blades.
d
13. During the morning rounds a nurse assesses the client's condition. The client had major heart surgery 2 days ago. His vital signs are stable, and his incision is clean and healing well. He complains of incisional pain. The nurse finds that the IV infusion is running on time, but only 100 ml remains before the IV bag runs out. An order exists for the IV infusion to continue. Which of the following actions is the highest priority for the nurse at this time? a. Replacing the IV bag with a new one. b. Instructing the client on complications of wound healing. c. Determining if the pharmacy has delivered IV solutions ordered for the next day. d. Administering an analgesic to the client for his incisional pain.
d
17. The nurse is caring for four diabetic patients. Which of these activities would be appropriate to delegate to the nursing assistant? a. Monitor a patient with a blood glucose of 68 mg/dL for tremors and irritability. b. Check on a patient complaining of palpitations and anxiety. c. Verify the infusion rate on a continuous infusion insulin pump. d. Perform hourly bedside blood glucose checks for a patient with hyperglycemia.
d
21. Which patient on the neurologic unit should the charge nurse assign to an LPN/LVN? A Patient with: a. an acute subdural hematoma who has an intracranial pressure (ICP) monitor in place. b. a severe diffuse axonal injury whose family is trying to decide about organ donation. c. a history of recent cocaine use who has left-sided weakness secondary to a hemorrhagic stroke. d. a closed head injury who has a Glasgow Coma Scale score of 13 and needs frequent reorientation.
d
32. Which information about a patient who was admitted with pelvic and bilateral femoral fractures after being crushed by a tractor is most important to report to the physician? The patient('s): a. thighs have multiple oozing abrasions. b. hemoglobin level is 12.0 g/dL. c. is complaining of pain at a level 4 (0-to-10 scale). d. serum potassium level is 7 mEq/L.
d
