NSG223 Module 4: Prioritization & Delegation

After the change of shift, the nurse is assigned to care for the following patients. Which patient should the nurse assess first?

A 51-year-old patient with asthma who reports short-ness of breath after using a bronchodilator inhaler

The critical care charge nurse is responsible for the care of four patients receiving mechanical ventilation. Which patient is most at risk for failure to wean and ventilator dependence?

A 68-year-old patient with a history of smoking and emphysema

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

A 72-year-old patient who needs teaching about the use of incentive spirometry

When a patient with tuberculosis (TB) is being pre-pared for discharge, which statement by the patient indicates a need for further teaching?

"I will continue to take my isoniazid until I am feeling completely well."

The RN is teaching an assistive personnel (AP) to check oxygen saturation by pulse oximetry. What will the nurse be sure to tell the AP about patients with darker skin?

"Usually, dark-skinned patients show a 3% to 5% lower oxygen saturation by pulse oximetry than light-skinned patients."

The RN clinical instructor is discussing a patient's oxygen-hemoglobin dissociation curve with a student (Figure 6.1). The student states that the patient's oral body temperature is elevated at 100.8°F (38.2°C). Which statement by the student indicates correct understanding of this patient's curve shift?

"When the patient's body temperature is elevated, there is a shift to the right so that hemoglobin will dissociate oxygen faster."

The nurse is providing care for a patient diagnosed with laryngeal cancer who is receiving radiation therapy. The patient tells the nurse that he is experiencing hoarseness and difficulty with speaking. What is the nurse's best response?

"Your voice should improve in 6 to 8 weeks after completion of the radiation."

The nurse is supervising an RN who floated from the medical-surgical unit to the emergency department. The float nurse is providing care for a patient admit-ted with anterior epistaxis (nosebleed). Which directions would the supervising nurse clearly provide to the RN? Select all that apply.

Apply ice or cool compresses to the nose. Maintain standard body substance precautions. Teach the patient to avoid vigorous nose blowing. Instruct the patient not to blow the nose for several hours. Apply direct lateral pressure to the nose for 5 minutes.

The assistive personnel (AP) tells the nurse that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should the nurse suggest to the AP to improve the patient's comfort?

Apply water-soluble jelly to the nares.

A patient has chronic obstructive pulmonary dis-ease. Which intervention for airway management should the nurse delegate to the assistive personnel (AP)?

Assisting the patient to sit up on the side of the bed

Which intervention for a patient with a pulmonary embolus would the RN assign to the LPN/LVN on the patient care team?

Auscultating the lungs for crackles

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

Administering medications via metered-dose inhaler (MDI). Checking oxygen saturation using pulse oximetry. Auscultating breath sounds.

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse instruct the nursing student to report immediately?

Continuous bubbling in the water-seal chamber

After extubation of a patient, which finding would the nurse report to the health care provider immediately?

Crowing noise during inspiration

The nurse is providing care for a patient with recently diagnosed asthma. Which key points would the nurse be sure to include in the teaching plan for this patient? Select all that apply.

Keep a symptom and intervention diary to learn specific triggers for your asthma. Avoid foods prepared with monosodium glutamate. 6. Keep a symptom and intervention diary to learn specific triggers for your asthma. Be sure to get at least 8 hours of rest and sleep every night. Use the inhaler 30 minutes before exercising to prevent bronchospasm. Avoid potential environmental asthma triggers such as smoke.

The high-pressure alarm on a patient's ventilator goes off. When the nurse enters the room to assess the patient, who has acute respiratory distress syndrome, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take first?

Manually ventilate the patient while assessing possible reasons for the high-pressure alarm.

The nurse is the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with acute respiratory distress syndrome who has just been intubated in preparation for mechanical ventilation. The preceptor observes the RN performing all of these actions. For which action must the preceptor intervene immediately?

Marks the tube 1 cm from where it touches the incisor tooth or nares

A patient with chronic obstructive pulmonary disease has rapid shallow respirations. Which is an appropriate action to assign to the experienced LPN/LVN un-der RN supervision?

Observing how well the patient performs pursed-lip breathing

A patient with chronic obstructive pulmonary disease tells the assistive personnel (AP) that he did not get his annual flu shot this year and has not had a pneumonia vaccination. Which vital sign reported by the AP is most important for the nurse to report to the health care provider?

Oral temperature of 101.2°F (38.4°C)

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements continue to show poor oxygenation. Which action does the nurse anticipate that the health care provider (HCP) will prescribe?

Perform endotracheal intubation and initiate mechanical ventilation.

The nurse is initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should the nurse delegate to the assistive personnel (AP)?

Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake

The nurse is supervising a student nurse who is per-forming tracheostomy care for a patient. Which action by the student would cause the nurse to intervene?

Removing the inner cannula and cleaning using standard precautions

The nurse is 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 the nurse immediately?

Respiratory rate of 8 breaths/min.

When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxy-gen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate?

Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (Fio2) and call the health care provider (HCP) to discuss the patient's status.

The nurse is assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should the nurse delegate to an experienced assistive personnel (AP)?

Taking vital signs and pulse oximetry readings every 4 hours

The nurse has just finished assisting the health care provider (HCP) 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 most important to report to the HCP?

The blood pressure is 100/48 mm Hg, and the heart rate is 102 beats/min.

The nurse is 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 (venous thromboembolism). The patient's only medication is enoxaparin subcutaneously. Which assessment information will the nurse need to communicate to the health care provider (HCP)?

The patient is unable to remember her husband's first name.

The nurse is admitting a patient for whom a diagnosis of pulmonary embolus (PE) must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of PE?

The patient was recently in a motor vehicle crash.

The RN is supervising a nursing student who will suction a patient on a mechanical ventilator. Which actions indicate that the student has a correct under-standing of this procedure? Select all that apply.

The student nurse applies suction during catheter removal. The student nurse uses a no. 12 French catheter. The student nurse uses a sterile catheter and glove. The student nurses use a twirling motion when withdrawing the catheter.

After the respiratory therapist performs suctioning on a patient who is intubated, the assistive personnel (AP) measures vital signs for the patient. Which vital sign value should the AP be instructed to report to the RN immediately?

Tympanic temperature of 101.4°F (38.6°C)

The nurse is the team leader RN working with a student nurse. The student nurse is teaching a patient how to use a metered-dose inhaler (MDI) without a spacer. Put in the correct order the steps that the student nurse should teach the patient.

Before each use, the cap is removed, and the inhaler is shaken according to the instructions in the package insert. Next the patient should breathe out completely. As the patient begins to breathe in deeply through the mouth, the canister should be pressed down to release 1 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 at least 1 minute between puffs from the inhaler.

Which of the following statements made by the patient are important with regard to her COPD? Select all that apply.

I get short of breath when I walk more than 2 blocks. I've had a cough for about 4 weeks now. I rest better at night when I sleep in my recliner chair. I'm afraid that I'll need home oxygen soon and I still smoke 5 to 6 cigarettes a day. I use my inhalers just twice a day.

A patient with chronic obstructive pulmonary disease (COPD) tells the nurse that he is always tired. What advice would the nurse give this patient to cope with his fatigue? Select all that apply.

Do not rush through your morning activities of daily living. Organize your work area so that what you use most is easy to reach. Avoid working with your arms raised. 3. Eat three large meals every day focusing on calories and protein. Don't hold your breath while performing any activities.

Case Study and Question: The nurse is supervising a nursing student providing care for a patient with shortness of breath who has expressed interest in smoking cessation. Which questions would the nurse suggest the student ask to determine nicotine dependence? Select all that apply.

Do you smoke when you are ill? How soon after you wake up in the morning do you smoke? Have you ever tried to quit smoking? Do you have a difficult time not smoking in places where it is not allowed? Do you wake up in the middle of your sleep time to smoke? Has anyone in your family developed lung cancer?

The assistive personnel (AP) is helping with feeding for a patient with severe end-stage chronic obstructive pulmonary disease (COPD). Which instruction will the nurse provide the AP?

Encourage the patient to eat foods that are high in calories and protein.

The nurse is responsible for the care of a postoperative patient with a thoracotomy. Which action should the nurse delegate to the assistive personnel (AP)?

Encouraging, monitoring, and recording nutrition-al intake.