Chapter 6- prioritization, delegation, & assignment questions

Which intervention for a patient with a pulmonary embolus would the RN assign to the LPN/LVN on the patient care team? 1. Evaluating the patient's reports of chest pain 2. Monitoring laboratory values for changes in oxygenation 3. Assessing for symptoms of respiratory failure 4. Auscultating the lungs for crackles

4. Auscultating the lungs for crackles

After extubation of a patient, which finding would the nurse report to the health care provider immediately? 1. Respiratory rate of 25 breaths/min 2. Patient has difficulty speaking 3. Oxygen saturation of 93% 4. Crowing noise during inspiration

4. Crowing noise during inspiration

A patient with chronic obstructive pulmonary disease (COPD) tells the unlicensed assistive personnel (UAP) that he did not get his annual flu shot this year and has not had a pneumonia vaccination. Which vital sign change will be most important for the nurse to instruct the UAP to report? 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 (38.4°C)

4. Oral temperature of 101.2°F (38.4°C)

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 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% fraction of inspired oxygen (FIO2) and call the health care provider to discuss the patient's status.

4. Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (FIO2) and call the health care provider to discuss the patient's status.

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

4. 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 to teach a patient how to use a metered-dose inhaler (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 (2.5 to 5.0 cm) away. 3. Breathe out completely. 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.

1, 3, 2, 5, 4, 6

The nurse is acting as preceptor for a newly-graduated RN during the second week of orientation. The nurse would assign and supervise the new RN to provide nursing care for which patients? Select all that apply. 1. A 38-year-old patient with moderate persistent asthma awaiting discharge 2. A 63-year-old patient with a tracheostomy needing tracheostomy care every shift 3. A 56-year-old patient with lung cancer who has just undergone left lower lobectomy 4. A 49-year-old patient just admitted with a new diagnosis of esophageal cancer 5. A 76-year-old patient newly diagnosed with type 2 diabetes 6. A 69-year-old patient with emphysema to be discharged tomorrow

1. A 38-year-old patient with moderate persistent asthma awaiting discharge 2. A 63-year-old patient with a tracheostomy needing tracheostomy care every shift 6. A 69-year-old patient with emphysema to be discharged tomorrow

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? 1. A 68-year-old patient with a history of smoking and emphysema 2. A 57-year-old patient who experienced a cardiac arrest 3. A 49-year-old postoperative patient who had a colectomy 4. A 29-year-old patient who is recovering from flail chest

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

A patient has chronic obstructive pulmonary disease (COPD). Which intervention for airway management should the nurse delegate to the unlicensed assistive personnel (UAP)? 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. Auscultating breath sounds every 4 hours

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

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. 1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler (MDI) 3. Completing in-depth admission assessment 4. Checking oxygen saturation using pulse oximetry 5. Developing the nursing care plan 6. Evaluating the patient's technique for using MDIs

1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler (MDI) 4. Checking oxygen saturation using pulse oximetry

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. 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). 6. Keep a symptom and intervention diary to learn specific triggers for your asthma.

1. Avoid potential environmental asthma triggers such as smoke. 2. Use the inhaler 30 minutes before exercising to prevent bronchospasm. 4. Be sure to get at least 8 hours of rest and sleep every night. 5. Avoid foods prepared with monosodium glutamate (MSG). 6. Keep a symptom and intervention diary to learn specific triggers for your asthma.

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. 1. Do not rush through your morning activities of daily living. 2. Avoid working with the arms raised. 3. Eat three large meals every day focusing on calories and protein. 4. Organize your work area so that what you use most is easy to reach. 5. Get all of your activities accomplished then take a nap. 6. Don't hold your breath while performing any activities.

1. Do not rush through your morning activities of daily living. 2. Avoid working with the arms raised. 4. Organize your work area so that what you use most is easy to reach. 6. Don't hold your breath while performing any activities.

The unlicensed assistive personnel (UAP) is assisting with feeding for a patient with severe end-stage chronic obstructive pulmonary disease (COPD). Which instruction will the nurse provide the UAP? 1. Encourage the patient to eat foods that are high in calories and protein. 2. Feed the patient as quickly as possible to prevent early satiety. 3. Offer lots of fluids between bites of food. 4. Try to get the patient to eat everything on the tray.

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

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. 1. How soon after you wake up in the morning do you smoke? 2. Do other members of your family smoke? 3. Do you smoke when you are ill? 4. Do you wake up in the middle of your sleep time to smoke? 5. Do you smoke indoors or outside? 6. Do you have a difficult time not smoking in places where it is not allowed?

1. How soon after you wake up in the morning do you smoke? 3. Do you smoke when you are ill? 4. Do you wake up in the middle of your sleep time to smoke? 6. Do you have a difficult time not smoking in places where it is not allowed?

The unlicensed assistive personnel (UAP) 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 UAP to improve the patient's comfort for this problem? 1. Humidify the patient's oxygen. 2. Use a simple face mask instead of a nasal cannula. 3. Provide the patient with an extra pillow. 4. Have the patient sit up in a chair at the bedside.

1. Humidify the patient's oxygen.

A patient with chronic obstructive pulmonary disease (COPD) has rapid shallow respirations. Which is an appropriate action to assign to the experienced LPN/LVN under RN supervision? 1. Observing how well the patient performs pursed-lip breathing 2. Planning a nursing care regimen that gradually increases activity tolerance 3. Assisting the patient with basic activities of daily living (ADLs) 4. Consulting with the physical therapy department about reconditioning exercises

1. Observing how well the patient performs pursed-lip breathing

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 will prescribe? 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 immediately (STAT). 4. Call a code for respiratory arrest.

1. Perform endotracheal intubation and initiate mechanical ventilation.

The nurse is 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 crash. 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.

1. 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 understanding of this procedure? Select all that apply. 1. The student nurse uses a sterile catheter and glove. 2. The student nurse applies suction while inserting the catheter. 3. The student nurse applies suction during catheter removal. 4. The student nurses uses a twirling motion when withdrawing the catheter. 5. The student nurse uses a no. 12 French catheter. 6. The student nurse applies suction for at least 20 seconds.

1. The student nurse uses a sterile catheter and glove. 3. The student nurse applies suction during catheter removal. 4. The student nurses uses a twirling motion when withdrawing the catheter. 5. The student nurse uses a no. 12 French catheter.

A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would the nurse give the unlicensed assistive personnel (UAP) who will help the patient with activities of daily living (ADLs)? 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. 6. Assess the patient for any signs or symptoms of bleeding.

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. 5. Be sure the patient's footwear has a firm sole when the patient ambulates.

When a patient with tuberculosis (TB) is being prepared for discharge, which statement by the patient indicates a 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."

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

The RN is teaching an unlicensed assistive personnel (UAP) to check oxygen saturation by pulse oximetry. What will the nurse be sure to tell the UAP about patients with darker skin? 1. "Be aware that patients with darker skin usually show a 3% to 5% higher oxygen saturation compared with light-skinned patients." 2. "Usually dark-skinned patients show a 3% to 5% lower oxygen saturation by pulse oximetry than light-skinned patients." 3. "With a dark-skinned patient, you may get more accurate results by measuring pulse oximetry on the patient's toes." 4. "More accurate results may result from continuous pulse oximetry monitoring than spot checking when a patient has darker skin."

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

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? 1. "Let's elevate the head of your bed and see if that helps." 2. "Your voice should improve in 6 to 8 weeks after completion of the radiation." 3. "Sometimes patients also experience dry mouth and difficulty with swallowing." 4. "I will call your health care provider and let him know about this."

2. "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 admitted with anterior epistaxis (nosebleed). Which directions would the supervising nurse clearly provide 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 standard body substance precautions. 4. Apply ice or cool compresses to the nose. 5. Instruct the patient not to blow the nose for several hours. 6. Teach the patient to avoid vigorous nose blowing.

2. Apply direct lateral pressure to the nose for 5 minutes. 3. Maintain standard body substance precautions. 4. Apply ice or cool compresses to the nose. 5. Instruct the patient not to blow the nose for several hours. 6. Teach the patient to avoid vigorous nose blowing.

The nurse is caring for a patient after thoracentesis. Which actions can be delegated from the nurse to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Assess puncture site and dressing for leakage. 2. Check vital signs every 15 minutes for 1 hour. 3. Auscultate for absent or reduced lung sounds. 4. Remind the patient to take deep breaths. 5. Take the specimens to the laboratory. 6. Teach the patient symptoms of pneumothorax.

2. Check vital signs every 15 minutes for 1 hour. 4. Remind the patient to take deep breaths. 5. Take the specimens to the laboratory.

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? 1. Chest tube drainage of 10 to 15 mL/hr 2. Continuous bubbling in the water-seal chamber 3. Reports of pain at the chest tube site 4. Chest tube dressing dated yesterday

2. Continuous bubbling in the water-seal chamber

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

2. Encouraging, monitoring, and recording nutritional intake

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 (ARDS), the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take first? 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 (FIO2) 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.

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

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? 1. Fine bibasilar crackles 2. Respiratory rate of 8 breaths/min 3. The patient sitting up and leaning over the nightstand 4. A large barrel chest

2. Respiratory rate of 8 breaths/min

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

2. Taking vital signs and pulse oximetry readings every 4 hours

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? 1. A 58-year-old patient on airborne precautions for tuberculosis (TB) 2. A 65-year-old patient who just returned from bronchoscopy and biopsy 3. A 72-year-old patient who needs teaching about the use of incentive spirometry 4. A 69-year-old patient with chronic obstructive pulmonary disease (COPD) who is ventilator dependent

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

The nurse is 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 bed at a 30- to 45-degree angle. 4. Suction the airway when coarse crackles are audible.

3. Maintain the head of bed at a 30- to 45-degree angle.

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 (ARDS) 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? 1. Assesses for bilateral breath sounds and symmetrical chest movement 2. Uses an end tidal carbon dioxide detector to confirm endotracheal tube (ET) position 3. Marks the tube 1 cm from where it touches the incisor tooth or nares 4. Orders chest radiography to verify that tube placement is correct

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

A patient with a diagnosis of sleep apnea has a problem with sleep deprivation related to a disrupted sleep cycle. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Discussing weight-loss strategies such as diet and exercise with the patient 2. Teaching the patient how to set up the bilevel positive airway pressure (BiPAP) machine before sleeping 3. Reminding the patient to sleep on his side instead of his back 4. Administering modafinil to promote daytime wakefulness

3. Reminding the patient to sleep on his side instead of his back

The nurse is initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Teaching the patient about the importance of adequate 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, and then cough two or three times in succession

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

The nurse is supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause the nurse to 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 standard precautions 4. Replacing the inner cannula and cleaning the stoma site

3. Removing the inner cannula and cleaning using standard precautions

The nurse has just finished assisting the health care provider 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 health care provider (HCP)? 1. The patient starts crying and says she can't go on with treatment much longer. 2. The patient reports sharp, stabbing chest pain with every deep breath. 3. The blood pressure is 100/48 mm Hg, and the heart rate is 102 beats/min. 4. The dressing at the thoracentesis site has 1 cm of bloody drainage.

3. 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? 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 abdomen

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

The RN clinical instructor is discussing a patient's oxygen-hemoglobin dissociation curve with a student. 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? 1. "When a patient's body temperature is elevated, there is no change in the oxygen-hemoglobin dissociation curve." 2. "When a patient's body temperature is elevated, there is a shift to the left because the oxygen tension level is lower." 3. "When a patient's body temperature is elevated, there is no shift in the curve because the patient is using less oxygen." 4. "When the patient's body temperature is elevated, there is a shift to the right so that hemoglobin will dissociate oxygen faster."

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

After change of shift, the nurse is assigned to care for the following patients. Which patient should the nurse assess first? 1. A 68-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the laboratory 2. A 57-year-old patient with chronic obstructive pulmonary disease (COPD) and a pulse oximetry reading from the previous shift of 90% saturation 3. A 72-year-old patient with pneumonia who needs to be started on IV antibiotics 4. A 51-year old patient with asthma who reports shortness of breath after using a bronchodilator inhaler

4. A 51-year old patient with asthma who reports shortness of breath after using a bronchodilator inhaler