Prioritization application questions
Clients in which situations should be assigned to an experienced RN? (select all that apply) a. Sustained multiple injuries in a car crash b. Has chronic back pain from a work injury c. Returned from surgery with a chest tube d. Experiencing abdominal cramps from food poisoning e. Reports a severe headache of unknown origin f. Reports chest pain and a history of arteriosclerosis
A, C, E, F
The home health nurse is planning visits for today. The nurse begins visits at 9 am and all clients live within a 5 mile radius. List in order of priority how the nurse should plan the order of visits for the day. a. Requiring twice daily abdominal dressing changes b. With diabetes who needs fasting blood glucose drawn c. Who will be seen by the aide at 10 am and the RN needs to orient the aide and provide supervision of the cares d. Whose spouse is performing daily dressing changes and the nurse needs to supervise e. Who was discharged yesterday from the hospital following a diagnosis of pneumonia and needs to be admitted to home health care
1: B 2: A 3: C 4: D 5: E
A client is crying and grimacing but refuses pain medication because "my brother is a drug addict and has ruined our lives". What is the priority intervention for this client? a. Encourage expressions of fears and past experiences b. Provide accurate information about the use of pain medication c. Explain that addiction is unlikely among acute care clients d. Seek family assistance in resolving this problem
A
The charge nurse is collaborating with the HCP for transfer of clients from the med-surg unit to the meds unit to make room for clients from an external disaster. Which client would be best to transfer to the pediatric floor? a. Client with a suspected appendicitis b. Client with chest pain c. Client who is post mastectomy d. Client who is about to undergo colon resection
A
The nurse working on an adult medical-surgical unit would ideally assign which client to the LPN under the supervision of the RN? a. A 45 year old admitted yesterday after a nephrectomy b. A 78 year old with diabetes mellitus and slow-healing foot ulcer c. A 32 year old with a fractured pelvis from an automobile accident 2 days earlier d. A 62 year old returning from an open pelvic exploration receiving medication via a patient controlled analgesia
B
Which task is appropriate for the nurse to delegate to an experienced nursing assistant? a. Obtain 24 hour debt recall from a patient recently admitted with anorexia nervosa b. Obtain clean catch urine specimen from a patient suspected of having a UTI c. Observe the amount of characteristics of the return from a continuous bladder irrigation for a patient after a transurethral resection d. Observe a patient newly diagnosed with diabetes mellitus practice injections using an orange
B
Which clients are best to assign to an LPN who will function under the supervision of an RN? (select all that apply) a. Client who needs pre op teaching about the PCA pump b. Client with a leg cast who needs neurofibromatosis-circ checks and PRN hydrocodone c. Client who underwent a toe amputation. and has diabetic neuropathic pain d. Client with terminal cancer and severe pain who is refusing medication e. Client who reports abdominal pain after being kicked and beaten f. Client with arthritis who needs scheduled pain meds and heat applications
B, C, F
Which clients are most appropriately assigned to a newly graduated RN who has recently completed orientation? (select all that apply) a. Anxious client with chronic pain who frequently uses the call button b. Client on second post op day who needs pain meds before dressing changes c. Client with AIDS who reports HA, abdominal and pleuritic chest pain d. Client with chronic pain to be discharged with a new surgically implanted catheter e. Client reporting pain at the site of peripheral IV f. Client with a kidney stone who needs frequent PRN pain meds
B, E, F
A nurse plans to assign some responsibilities of client care to a LPN. Which task is best? a. Routine vital signs for a stable client b. Monitoring fluid balance of a postoperative patient c. Removing staples from a clients incision d. Triage of clients as they enter the emergency room
C
After receiving a report form the night nurse, which patient should the nurse see first? a. A 31 year old woman refusing Carafate before breakfast b. A 40 year old man with left-sided weakness asking for assistance to the bedside commode c. A 52 year old woman complaining of chills who is scheduled for a cholecystectomy d. A 65 year old man with a nasogastric tube who had a bowel resection yesterday
C
The charge nurse eon a med surgeon unit is working with a newly graduate RN who has been on orientation to the unit for three weeks. Which client is best to assign to the new grad? a. A 34 year old just admitted to the unit with periorbital cellulitis b. A 40 year old who needs discharge instructions after having skin grafts to the thigh c. A 67 year old who requires a dressing change after hydrotherapy for a pressure ulcer d. A 78 year old who needs teaching before a biopsy of a facial lesion
C
The nurse has just received hand-off report in the burn unit. Which client requires the most immediate assessment or intervention? a. A 22 year old admitted 4 days ago with facial burns from a fire who has been crying since recent visitors left b. A 34 year old who returned from skin graft surgery 3 hours ago and is reporting level 8 out of 10 pain c. A 45 year old with partial thickness leg burns who has a temp of 102.6 F (39.2 C) and BP of 98/46 d. A 57 year old admitted with electrical burns 24 hours ago and has a blood potassium level of 4.9 mEq/L
C
A home care nurse is planning visits for the day. Which client should the nurse visit first? a. A 62 year old man two days after laparoscopic inguinal hernia repair b. A 40 year old women with type 2 diabetes mellitus c. A 76 year old man with COPD d. A 50 year old women two days after a right mastectomy with two JP drains
D
The nurse is bathing a client when a nursing assistant enters to report that another client needs pain meds. Which action would be best? a. Finish the bed bath and then administer the pain med b. Ask the NA to find out a pain score and when the last pain med was given to the client c. Ask the NA to tell the client tin pain that meds will be given as soon as the nurse ifnishes a bath d. Delegate the remainder of the bath to the NA and go give the pain medication to the other client
D
The team is providing emergency care to a client who received an excessive dose of opioid pain medication. Which task is best to delegate to the LPN? a. Calling the health care provider to provide SBAR report b. Giving naloxone and evaluating response to therapy c. Monitoring the respiratory status for the first 30 min d. Applying oxygen per nasal canal as ordered
D
The nursing assistant reports that a client with COPD is in the chair and reports feeling short of breath after eating breakfast. Which action should the RN take first? a. Increase oxygen flow rate b. Obtain oxygen saturation level c. Ask the NA to assist client to bed d. Contact the respiratory therapist
b. Obtain oxygen saturation level
A registered nurse must complete a pain assessment on a new post op client and decides to assign incision care for another client to the CNA. Which specific delegation right has the nurse breached? a. Supervision b. Task c. Circumstances d. Person
b. Task
The RN assignment includes: client needing IV push morphine for leg pain rated 7/10; client with am doses of digoxin and furosemide for heart failure; client with prophylactic subcut. heparin; and a client who needs an enteral feeding bolus. Which task takes priority? a. Heparin to prevent blood clots b. Medications to treat HF c. Morphine IV push to treat pain d. Bolus of the enteral feeding for nutrition
c. Morphine IV push to treat pain
Which intervention for a client with pneumonia could be assigned to the LPN? a. Evaluate complaints of chest pain b. Monitor lab values for change in oxygenation c. Assess for symptoms of respiratory failure d. Auscultate lung sounds for crackles
d. Auscultate lung sounds for crackles
The nurse enters a hospital room and sees the client lying on the floor next to the bed. Which action should the nurse take first? a. Complete an incident report b. Notify the clients provider c. Move the client back to bed d. Obtain the clients vital signs
d. Obtain the clients vital signs
