Nursing Prioritization, Delegation And Assignment NCLEX Quiz #1 (10 Questions)

1. A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant (PCT)?

Discuss weight-loss strategies such as diet and exercise with the patient

Teach the patient how to set up the BiPAP machine before sleeping

Remind the patient to sleep on his side instead of his back.

Administer modafinil (Provigil) to promote daytime wakefulness

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. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can delegate administration of medication to an LPN/LVN.

Explanation

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. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can delegate administration of medication to an LPN/LVN.

2. After change of shift. you are assigned to care for the following patients. Which patient should you assess first?

A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab

A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation

A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics

A 50-year old with asthma who complains of shortness of breath after using a bronchodilator

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. The other patients need to be assessed as soon as possible. but none of their situations are urgent. in COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable.

Explanation

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. The other patients need to be assessed as soon as possible. but none of their situations are urgent. in COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable.

3. A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (PCT)?

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

Instructing the patient to cough effectively

Teaching the patient to use incentive spirometry

Auscultation of breath sounds every 4 hours

Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of a nursing assistant. Teaching. instructing. and assessing patients all require additional education and skills and are more appropriate for a licensed nurse.

Explanation

Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of a nursing assistant. Teaching. instructing. and assessing patients all require additional education and skills and are more appropriate for a licensed nurse.

4. A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient's care?

Perform postural drainage and chest physiotherapy every 4 hours

Allow the patient to decide whether she needs aerosolized medications

Place the patient in a private room to decrease the risk of further infection

Plan activities to allow at least 8 hours of uninterrupted sleep

Airway clearance techniques are critical for patients with cystic fibrosis and should take priority over the other activities. Although allowing more independent decision making is important for adolescents. the physiologic need for improved respiratory function takes precedence at this time. A private room may be desirable for the patient but is not necessary. With increased shortness of breath. it will be more important that the patient have frequent respiratory treatments than 8 hours of sleep.

Explanation

Airway clearance techniques are critical for patients with cystic fibrosis and should take priority over the other activities. Although allowing more independent decision making is important for adolescents. the physiologic need for improved respiratory function takes precedence at this time. A private room may be desirable for the patient but is not necessary. With increased shortness of breath. it will be more important that the patient have frequent respiratory treatments than 8 hours of sleep.

5. The high-pressure alarm on a patient's ventilator goes off. When you enter the room to assess the patient. who has ARDS. the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next?

Reassure the patient that the ventilator will do the work of breathing for him

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

Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning

Insert an oral airway to prevent the patient from biting on the endotracheal tube

Manual ventilation of the patient will allow you to deliver an FiO2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. The patient may need reassurance. suctioning. and/or insertion of an oral airway. but the first step should be assessment of the reason for the high-pressure alarm and resolution of the hypoxemia.

Explanation

Manual ventilation of the patient will allow you to deliver an FiO2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. The patient may need reassurance. suctioning. and/or insertion of an oral airway. but the first step should be assessment of the reason for the high-pressure alarm and resolution of the hypoxemia.

6. After the respiratory therapist performs suctioning on a patient who is intubated. the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the RN immediately?

Heart rate of 98 beats/min

Respiratory rate of 24 breaths/min

Blood pressure of 168/90 mm Hg

Tympanic temperature of 101.4 F (38.6 C)

Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body’s normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the respiratory system.

Explanation

Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body’s normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the respiratory system.

7. A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather mask. but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care. you would anticipate a physician order for what action?

Perform endotracheal intubation and initiate mechanical ventilation

Immediately begin continuous positive airway pressure (CPAP) via the patient’s nose and mouth

Administer furosemide (Lasix) 100 mg IV push stat

Call a code for respiratory arrest

A non-rebreather mask can deliver nearly 100% oxygen. When the patient’s oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration. refractory hypoxemia is present. Usually at this stage. the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient’s work of breathing.

Explanation

A non-rebreather mask can deliver nearly 100% oxygen. When the patient’s oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration. refractory hypoxemia is present. Usually at this stage. the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient’s work of breathing.

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

A 58-year old on airborne precautions for tuberculosis (TB)

A 68-year old just returned from bronchoscopy and biopsy

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

A 69-year old with COPD who is ventilator dependent

Many surgical patients are taught about coughing. deep breathing. and use of incentive spirometry preoperatively. To care for the patient with TB in isolation. the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized procedure. and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.

Explanation

Many surgical patients are taught about coughing. deep breathing. and use of incentive spirometry preoperatively. To care for the patient with TB in isolation. the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized procedure. and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.

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

Auscultate breath sounds

Administer medications via metered-dose inhaler (MDI)

Complete in-depth admission assessment

Initiate the nursing care plan

Evaluate the patient’s technique for using MDI’s

The experienced LPN is capable of gathering data and making observations. including noting breath sounds and performing pulse oximetry. Administering medications. such as those delivered via MDIs. is within the scope of practice of the LPN. Independently completing the admission assessment. initiating the nursing care plan. and evaluating a patient’s abilities require additional education and skills. These actions are within the scope of practice of the professional RN.

Explanation

The experienced LPN is capable of gathering data and making observations. including noting breath sounds and performing pulse oximetry. Administering medications. such as those delivered via MDIs. is within the scope of practice of the LPN. Independently completing the admission assessment. initiating the nursing care plan. and evaluating a patient’s abilities require additional education and skills. These actions are within the scope of practice of the professional RN.

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10. A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply.

Use a lift sheet when moving and positioning the patient in bed

Use an electric razor when shaving the patient each day

Use a soft-bristled toothbrush or tooth sponge for oral care

Use a rectal thermometer to obtain a more accurate body temperature

Be sure the patient’s footwear has a firm sole when the patient ambulates

While 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). All of the other instructions are appropriate to the care of a patient receiving anticoagulants.

Explanation

While 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). All of the other instructions are appropriate to the care of a patient receiving anticoagulants.

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