Chapter 6 questions
A nurse is caring for a pt who has COPD and is 2 days postop after a laparoscopic cholecystectomy. Which intervention for airway management should the nurse delegate to the NAP? 1. Assisting the pt to sit up on the side of the bed 2. Instructing the pt to cough effectively 3. Teaching the pt to use spirometer 4. Auscultating breath sounds every 4 hours.
Ans: 1 assisting pts with positioning and ADL's is within their scope of practice as a NAP.
A nurse is caring for a pt with a PE. The pt is receiving anticoagulants with IV heparin. What instructions should the nurse give the NAP who will help the pt with ADL's? SATA 1. Use a lift sheet when moving and positioning the pt 2. Use an electric razor when shaving the pt each day 3. Use a soft bristled tooth brush or tooth sponge for oral care. 4. Use a rectal thermometer to obtain a more accurate temp 5. Be sure the pts footwear has a non slip sole when the pts ambulates.
Ans: 1,2,3,5 these are appropriate to the care of a pt receiving anticoagulants.
A nurse is caring for a pt who is diagnosed with coronary artery disease and sleep apnea. Which action should the nurse delegate to the NAP? 1. Discuss weight loss strategies such as diet and exercise with the pt. 2. Teach the pt how to set up the CPAP machine before sleeping 3. Remind the pt to sleep on his side instead of his back 4. Administer provigil to promote daytime wakefulness.
Ans: 3 the NAP can remind pts about actions that have already been taught by the nurse and are part of the pts plan of care.
An assistant nurse manager is making assignments for the next shift. Which pt should the assistant nurse manager assign to the nurse with 6 months of experience and who has been floated from the surgical unit to the medical unit? 1. A 58 y/o on airborne precautions for TB 2. A 68 y/o who just returned from bronchoscopy and biopsy 3. A 69 y/o with COPD who is vent dependent 4. A 72 y/o who needs teaching about the use of a incentive spirometer.
Ans: 4 many surgical pts are taught about coughing, deep breathing and the use of incentive spirometer preoperatively.
A respiratory therapist performs suctioning on a pt with a closed head injury that has a trach. Afterward, the NAP obtains VS. The nurse should communicate that the NAP needs to report which VS immediately? SATA 1. HR of 96bpm 2. RR of 24 breaths per min 3. Pulse ox of 95% 4. Tympanic temp of 101.4
Ans: 4 the pt has a trach and is at risk for infection. A tympanic temp of 101.4 indicates infection and needs to be reported immediately.
A nurse is assigned to care for the following pts . Which pt should the nurse assess first? 1. A 60 y/o pt on a vent for whom a sterile sputum specimen must be sent to the lab 2. A 55 y/o with COPD and pulse ox reading from the previous shift of 90% saturation. 3. A 70y/o with pneumonia who needs to be started on IV antibiotics 4. A 50 y/o with asthma who complains of SOB after using bronchodilator
Ans: 4 the pt with asthma did not achieve relief from SOB after treatment and is at risk for resp complications. This pts needs are urgent
The pt with COPD has a nursing diagnosis of ineffective breathing pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision? 1. Observe how well the pt performs pursed lip breathing 2. Plan a nursing care regimen that gradually increases activity intolerance. 3. Assist the pt with basic ADL's 4. Consult with the physical therapy department about reconditioning exercises.
Ans: 1 experienced LPN's can use observation of pts to gather data regarding how well pts perform interventions that have already been taught. Planning and consulting are done by an RN. Assisting with ADL's is more for a NAP.
A nurse is helping a NAP provide a bed bath to a comatose pt who is in continent. Which of the following actions requires the nurse to intervene? 1. The NAP answers the phone while wearing gloves 2. The NAP log rolls the pt to provide back care 3. The NAP places an incontinence diaper under the pt 4. The NAP positions the pt on the left side, head elevated.
Ans: 1 the gloves are contaminated and should be removed before answering the phone.
The NAP tells a nurse that a pt who is receiving oxygen at a flow rate of 6L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should the nurse suggest to improve the pts comfort of this problem? 1. Suggest that the pts oxygen be humidified 2. Suggest that a simple face mask be used instead of a nasal cannula 3. Suggest that the pt be provided with an extra pillow 4. Suggest that the pt sit up in a chair at the bedside.
Ans: 1 when the oxygen flow rate is higher than 4L/min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Application of water soluble jelly to the nares can also help decrease discomfort.
An experienced LPN is working under the supervision of an RN. The LPN is providing care for a pt who has a resp problem. Which activities should the RN delegate to the experienced LPN? SATA 1. Auscultation breath sounds 2. Administer medications via metered dose inhaler 3. Compare in depth admission assessment. 4. Initiate the nursing care plan 5. Evaluate the pts technique for using the inhaler.
Ans: 1,2 the experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse ox. Administering meds such as the inhaler is within the scope of practice.
