Delegation, Prioritization and Leadership

​The nurse is supervising the care of the patient prior to a surgical procedure who has been ordered to receive a clear liquid diet. Which food item, if provided to the patient by the unlicensed assistive personnel, prompts the nurse to intervene with further education? 

The nurse is caring for a 60-year-old female patient who is confined to bed and most closely monitors for signs of which complication?

The patient in the emergency room has a traumatic leg wound which has been cleaned and dressed. The nurse enters the room to reassess the wound prior to discharging the patient and notes bright red drainage on the dressing that is increasing in size. Which action does the nurse take first?

Which of the following statements by a nursing assistant indicates understanding of the nurse’s instructions regarding the care of a patient with failure to thrive?

A multiple-gunshot victim is brought by EMS to the emergency department, and subsequently expires. Which action by the nurse is completed first?

Which patient in the emergency department does the nurse assess first?

The patient presents to the urgent care clinic with a hand laceration sustained while using pruning shears in the garden. Which vaccine is most important for this patient?

The nurse finds a 70-year-old client admitted with heart failure, unresponsive with agonal gasping respirations. Which action does the nurse take first?

The patient presents to the emergency department complaining of a fever, cough, and runny nose. Upon assessment, the nurse notes Koplik spots inside the client’s mouth; the client’s temperature is 102.5 °F (39.1 °C). Which infection control measures does the nurse institute?

The patient is receiving a transfusion of packed red blood cells. After 30 minutes, the patient complains of intense itching and flank pain. Upon assessment, the nurse notes a fever and tachycardia. Which of the following is the next best step in management?

The patient complains of severe fatigue and joint pain. Upon assessment, the nurse notes the patient’s skin is bronzed. Which of the following physical assessments is most important?

A patient with hemochromatosis has just undergone a liver biopsy to assess for cirrhosis. For which complication must the nurse be vigilant in the hours following the procedure?

The nurse is a first responder to the scene of a motor vehicle accident in which the patient experienced burns to 35% of her body. Which action does the nurse take first?

The nurse in the emergency department is performing a primary assessment on a patient who has sustained significant burn injuries. Which of the following physical assessments does the nurse include in the primary survey?

Which patient involved in a mass casualty accident is treated at the scene first?

Which task can be performed by an unlicensed assistive personnel?

The patient has consistently reported 8/10 pain levels despite large doses of morphine being supplied. The nurse brings the patient’s IV morphine dose to the room to administer it. The patient states, “That is way more medication than the nurse gave me all night.” The nurse verifies the dose and amount and finds it consistent with the order and the amount that has been removed from the Pyxis. Which action by the nurse is appropriate?

Which patient does the nurse assess first?

The nurse is caring for a patient who cannot read or write. The patient has a surgical procedure tomorrow and needs to give informed consent. Which of the following is the correct role for the nurse to take for obtaining consent from this patient?

The nurse is assigned to a patient with acute lymphocytic leukemia (ALL) about to undergo his first round of chemotherapy. The patient’s WBC is 120,000/uL and his LDH is 3 times the upper limit of normal. Which intervention is most important?

The nurse is the charge nurse for the floor. During the shift, a patient is given triple the usual dose of his narcoleptic medication because the current pills were a different dosage than the nurse expected. There was no noticeable adverse effect on the patient from the increased dose and patient has no complaints about the error. Which of the following is the best course of action to take regarding this incident?

A nurse on an inpatient medical unit notices that multiple patients being admitted to the unit from the emergency department are not wearing ID bands. Which of the following is the most appropriate way to address this issue?

The nurse has received report on four patients at 0700. Which patient should the nurse assess first?

A patient hospitalized with ulcerative colitis develops worsening abdominal pain, a fever of 103 °F, heart rate of 132 bpm, and blood pressure of 82/54 mmHg. Her labs are notable for an elevated white blood cell count. What is the nurse’s first action?

The nurse is a first responder at a mass casualty event. According to the Simple Triage and Rapid Treatment (START) protocol, which patient will receive medical care first?

The nurse is a first responder following a multi-vehicle accident and performs triage on the victims while waiting for further assistance. A person walks up to the nurse with a minor head wound and asks to be treated. Which response by the nurse is appropriate?

The nurse is a first responder following a mass casualty incident and performs triage on these victims while waiting for assistance. List the patients in order they must be treated according to the Simple Triage and Rapid Treatment (START) protocol.

The nurse is working in the emergency department when a mass casualty event occurs. Which patient will the nurse treat first?

A patient is receiving multiple continuous infusions for the treatment of acute decompensated heart failure (ADHF). The nurse notes the patient’s central line, through which the drips are being infused, has cracked. After an alternate vascular access has been established, which drug should the nurse restart first?

The school nurse observes a child collapse and become unresponsive after being stung by a bee. Loud wheezes are audible. Which of the following treatments is most appropriate for this patient?

The nurse notes the physician has entered the room of a patient who is infected with methicillin-resistant staphylococcus aureus without proper personal protective equipment and begins assessing the patient. Which response by the nurse is most appropriate?

Following a motor vehicle accident, an organ donor is declared brain dead and the heart is procured at 0700 on Monday. By what time must the heart be transplanted into the recipient? Enter your number using military time (0000).

Donated lungs from a 28-year-old victim of a motorcycle accident have been procured and have matched to four people. Which patient will receive the lungs?

A kidney is procured at 0900 on Monday during a living donation. When is the latest it can be transplanted into the recipient?

The parents bring a previously toilet trained 3-year-old patient to the clinic reporting regular fecal incontinence. Which assessment is the priority?

The patient with a long history of intravenous drug abuse presents to the emergency department with white lesions on both sides of the tongue that change appearance every couple of days. Despite fatigue and recent weight loss, the patient’s assessment is normal. Which type of precautions does the nurse use for this patient?

The 4-hours-old neonate is brought to the special care nursery from the mother’s room for an assessment. The temperature is 35.4° Celsius. Which initial action does the nurse take?

Place the steps of therapeutic touch in the correct order.

An adolescent patient admitted to the hospital with anorexia nervosa is experiencing extreme fatigue. Which nursing intervention is most appropriate for providing hygiene care for this patient?

The patient appears to be fatiguing before daily bathing and grooming is finished. Which action by the nurse is most appropriate?

The nurse is supervising the care of a patient with a urinary catheter by an unlicensed assistive personnel (UAP). Which action by the UAP would prompt the nurse to intervene immediately?

The nurse is reviewing a patient’s intake and output and notes the patient’s output has dropped drastically over the past 12 hours. Which intervention does the nurse perform first?

A patient complains of constipation. Which instruction should the nurse give first?

Which vital sign reported by the unlicensed assistive personnel (UAP) does the nurse investigate first?

The patient with which assessment is to be treated first in the emergency department?

Which patient does the nurse visit first?

Which assessment requires the most immediate intervention?

Which assessments are considered second priority? Select all that apply

The nurse is the first responder to a multi-car accident on the highway. Which assessment does the nurse make first?

The bedside nurse delegates vital signs checks to an unlicensed assistive personnel (UAP) every four hours. Prior to the 1200 vital sign check, the UAP has a family emergency and leaves the unit without informing the nurse. As a result, the 1200 vitals are not completed. Who is responsible for this lapse in care?