Ch 6 Book and Lecture Questions
A respiratory therapist performs suctioning on a patient with a closed head injury who has a tracheostomy. Afterward, the NAP obtains vital signs. Th e nurse should communicate that the NAP needs to report which vital sign value or values immediately? Select all that apply. a) Heart rate of 96 beats/min b) Respiratory rate of 24 breaths/min c) Pulse oximetry of 95% d) Tympanic temperature of 101.4°F (38.6°C)
Answer: 4 Rationales: 1. Suctioning will increase the heart rate. This needs reporting and reassessment and may be related to the increased temperature. 2. Respiratory rate is often increased with a fever. 3. Pulse oximetry of 95% is acceptable. 4. Th e patient has a tracheostomy and is at risk for infection. A tympanic temperature of 101.4°F (38.6°C) indicates an infection and needs to be reported immediately.
The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision? a) Observe how well the patient performs pursed-lip breathing. b) Plan a nursing care regimen that gradually increases activity intolerance. c) Assist the patient with basic activities of daily living. d) Consult with the physical therapy department about reconditioning exercises
Answer: 1 Rationales: 1. Experienced licensed practical nurses (LPNs) and licensed vocational nurses (LVNs) can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. 2. Planning requires additional education and skills, appropriate to a registered nurse (RN). 3. Assisting patients with activities of daily living (ADLs) is more appropriately delegated to a nursing assistant. 4. Consulting requires additional education and skills, appropriate to an RN.
A nurse is assigned to care for the following patients. Which patient should the nurse assess fi rst? a)A 60-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the laboratory b) A 55-year-old with COPD and a pulse oximetry reading from the previous shift of 90% saturation c) A 70-year-old with pneumonia who needs to be started on IV antibiotics d) A 50-year-old with asthma who complains of shortness of breath after using a bronchodilator
Answer: 4 Rationales: 1. This patient's needs are not urgent or emergent. 2. In chronic obstructive pulmonary disease (COPD), patients' pulse oximetry oxygen saturations of more than 90% are acceptable. 3. The IV needs to be started; however, there is not an indication that the patient is in an urgent or emergent situation. 4. The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent.an RN.
An assistant nurse manager is making assignments for the next shift. Which patient should the assistant nurse manager assign to a nurse with 6 months of experience and who has been floated from the surgical unit to the medical unit? a) A 58-year-old on airborne precautions for tuberculosis (TB) b) A 68-year-old who just returned from bronchoscopy and biopsy c) A 69-year-old with COPD who is ventilator dependent d) A 72-year-old who needs teaching about the use of incentive spirometry
Answer: 4 Rationales: 1. To care for the patient with tuberculosis (TB) in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. 2. The bronchoscopy patient needs specialized procedure care and a more experienced nurse. 3. The ventilator-dependent patient needs a nurse who is familiar with ventilator care. 4. Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively.
A nurse is helping an NAP provide a bed bath to a comatose patient who is incontinent. Which of the following actions requires the nurse to intervene? a) The nursing assistant answers the phone while wearing gloves. b) The nursing assistant log-rolls the client to provide back care. c)The nursing assistant places an incontinence diaper under the client. d) The nursing assistant positions the client on the left side, head elevated.
Answer: 1 Rationales: 1. The gloves are contaminated and should be removed before answering the phone. 2. Log rolling is an appropriate action. 3. Using an incontinence diaper is an appropriate action. 4. Keeping the head elevated is an appropriate action
Under which model of care is the focus on the task and not necessarily holistic client care? A. Functional nursing B. Team nursing C. Total patient care D. Primary nursing
A When implementing functional nursing, the focus is on the task and not necessarily holistic client care. The needs of the clients are categorized by task, and then the tasks are assigned to the "best person for the job."
A nurse is caring for a patient who has chronic obstructive pulmonary disease (COPD) and is 2 days postoperative after a laparoscopic cholecystectomy. Which intervention for airway management should the nurse delegate to an NAP? a) Assisting the patient to sit up on the side of the bed b) Instructing the patient to cough effectively c)Teaching the patient to use incentive spirometry d) Auscultating breath sounds every 4 hours
Answer: 1 Rationales: 1. Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of a nursing assistant. 2. Instructing requires additional education and skills and is more appropriate for a licensed nurse. 3. Teaching patients requires additional education and skills and is more appropriate for a licensed nurse. 4. Assessing patients requires additional education and skills and is more appropriate for a licensed nurse.
The nursing assistant tells a nurse that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should the nurse suggest to improve the patient's comfort for this problem? a) Suggest that the patient ' s oxygen be humidifi ed. b) Suggest that a simple face mask be used instead of a nasal cannula. c)Suggest that the patient be provided with an extra pillow. d) Suggest that the patient sit up in a chair at the bedside.
Answer: 1 Rationales: 1. When the oxygen flow rate is higher than 4 L/min, the mucous membranes can be dried out. Th e best treatment is to add humidification to the oxygen delivery system. Application of a water-soluble jelly to the nares can also help decrease mucosal irritation. 2. This does not treat the problem. 3. This does not treat the problem. 4. This does not treat the problem.
An experienced LPN is working under the supervision of the RN. The LPN is providing nursing care for a patient who has a respiratory problem. Which activities should the RN delegate to the experienced LPN? Select all that apply. a) Auscultate breath sounds. b) Administer medications via metered-dose inhaler (MDI). c) Complete in-depth admission assessment. d) Initiate the nursing care plan. e) Evaluate the patient ' s technique for using MDIs.
Answer: 1, 2 Rationales: 1, 2. The experienced licensed practical nurse (LPN) is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via metered dose inhalers (MDIs), is within the scope of practice of the LPN. 3. Independently completing the admission assessment is within the scope of practice of the professional registered nurse (RN). 4. Initiating the nursing care plan is within the scope of practice of the professional RN. 5. Evaluating a patient's abilities requires additional education and skills. These actions are within the scope of practice of the professional RN.
A nurse is caring for a patient who has a pulmonary embolus. The patient is receiving anticoagulation with IV heparin. What instructions should the nurse give the NAP who will help the patient with activities of daily living? Select all that apply. a) Use a lift sheet when moving and positioning the patient in bed. b) Use an electric razor when shaving the patient each day. c)Use a soft-bristled toothbrush or tooth sponge for oral care. c) Use a rectal thermometer to obtain a more accurate body temperature. d) Be sure the patient ' s footwear has a non-slip sole when the patient ambulates
Answer: 1, 2, 3, 5 Rationales: 4. This is inappropriate. Although a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). 1, 2, 3, and 5. These are appropriate to the care of a patient receiving anticoagulants.
A nurse is caring for a patient who is diagnosed with coronary artery disease and sleep apnea. Which action should the nurse delegate to the NAP? a)Discuss weight-loss strategies such as diet and exercise with the patient. b) Teach the patient how to set up the CPAP machine before sleeping. c) Remind the patient to sleep on his side instead of his back. d) administer modafi nil (Provigil) to promote daytime wakefulness
Answer: 3 Rationales: 1. Discussing weight-loss strategies requires additional education and training. 2. Teaching requires additional education and training. Th ese actions are within the scope of practice of the registered nurse (RN). 3. The nursing assistant can remind patients about actions that have already been taught by the nurse and are part of the patient's plan of care. 4. The RN can delegate the administration of medication to a licensed practical nurse (LPN) or licensed vocational nurse (LVN).
Which of the following is a true statement? A. NAP's can replace registered nurses (RN's) if needed. B. There are specific criteria and regulations to consider when delegating. C. Delegation means assigning tasks. D. Supervision in nursing equates to authority.
B Various national organizations, states' nurse practice acts, and state boards of nursing have created criteria and regulations that inform the delegation of nursing tasks.
