Delegation, Prioritization and Leadership

The bedside nurse asks the unlicensed assistive personnel (UAP) to administer a tube feeding to a patient with a nasogastric tube. The UAP has never performed this task. Which action by the UAP is most appropriate?

Which aspect of delegation is the most crucial to ensure patient safety?

The unlicensed assistive personnel (UAP) performs a delegated task after failing to complete the yearly mandatory education and skills check-off and an adverse event occurs. Who is most responsible for the adverse event?

The bedside nurse asks the unlicensed assistive personnel (UAP) to help a stable patient to the bedside commode. Upon standing, the patient complains of being dizzy and lightheaded, but insists on using the commode. The UAP calls out to the bedside nurse for help, but the nurse had left the floor with another patient. The patient falls and sustains a mild head injury. Which individual is most responsible for the patient’s injury?

Which assessment does the nurse perform first in the unresponsive patient?

Which order does the nurse complete first in the patient with acute respiratory failure?

The nurse is assigned to a 32-year-old male admitted with bowel obstruction status post exploratory laparotomy. Which telephone call from the nurse to the provider is most appropriate?

The nurse calls the provider with this report: “Hi, Dr. Smith, the patient Mrs. Welch is complaining of an 8/10 pain in her lower abdomen. Her abdomen is distended but is soft with positive bowel sounds in all four quadrants. I have tried ambulation, warm compresses, and position changes, to no avail. Could you please come assess her?” Which component of SBAR communication does the nurse need to elaborate for this patient?

The nurse is assigned to care for several patients in the NICU. The nurse calls the advanced practice nurse about one of the patients and says, “Hello, this is Kelly Smith, a nurse working in the NICU. Can you please come assess the patient, Michael Doh, in bed 552? I’m concerned about him. Thanks!” Which component(s) of the SBAR communication does the nurse need to elaborate? Select all that apply.

The nurse is assigned several patients on the surgical floor. He calls the provider and says, “Hi there, the post-op day 1 in bed 14 asked me to call and request an order for increased dosage of his IV pain medication. His blood pressure has been consistently elevated and he has been tachycardic for the last 3 hours. Would you consider adding an adjuvant pain control medication?” Which aspect of this SBAR communication is most appropriate?

The nurse is preparing to draw blood from a patient who requires multiple laboratory tests. Which lab does the nurse draw first?

Following a mass casualty event, the nurse is called in to the hospital to work in accordance with the city's emergency response plan. The nurse is instructed to discharge as many current inpatients as possible to assist with reallocation of resources. Which patient is most appropriate to be discharged?

A fire has started in one of the medical surgical units, and the staff has been instructed to perform a horizontal evacuation. Which action does the nurse take first?

The nurse is assigned to care for a 65-year-old male patient who is diagnosed with atrial fibrillation. The nurse realizes during the shift report that six hours ago she administered 0.6 mg of this patient’s antiarrhythmic medication instead of 6.0 mg. Which action does the nurse perform first?

The nurse is assigned to care for a 14-year-old male who has repeatedly ripped out his IV line and attempted to harm himself with various objects found in the room despite a family member sitting at his bedside around the clock. He is placed in wrist restraints that are secured to the bed per physician order. If the current order was written at 1030, at what time that same day does the order expire?

A nurse is assigned to care for a 45-year-old male who is admitted for alcohol withdrawal. On the second day of admission, the patient becomes disoriented and combative, and the provider places him in bilateral wrist restraints. Which physical exam finding is most important for this patient?

The nurse would like to institute a process improvement project to improve the cleanliness of the patient rooms. Which key stakeholders does the nurse include? Select all that apply.

The nurse is making assignments for the oncoming shift in a stepdown unit. Which staff member is most appropriate to be assigned to the 74-year-old patient who has had a 3 year old tracheostomy connected to humidified oxygen, continuous gastrostomy feedings, and a peripherally-inserted central catheter for IV antibiotics who requires total care and turning every 2 hours?

The client presents to the emergency department following a blow to the abdomen during a baseball game. He is unresponsive with a blood pressure of 82/48 mmHg, heart rate of 118 bpm, a respiratory rate of 18, and an oxygen saturation of 95% on room air. The nurse anticipates taking which action first to treat this patient?

Prior to transporting a patient to surgery, the nurse ensures which items are in the patient's chart? Select all that apply. 

Upon arrival of the patient to the post-anesthesia recovery unit (PACU), which assessment does the nurse perform first?

Which statement by the novice nurse requires correction by the charge nurse?

Which patient must be treated first in the emergency department following a mass shooting?

Which process improvement project will be most effective in improving patient satisfaction?

Which observation prompts the nurse manager to implement a process improvement project on alarm fatigue in the unit?

Which situation in the hospital unit requires the most immediate attention?

Which patient is appropriate to assign to a licensed practical/vocational nurse (LPN/LVN)?

Which task in the care of a patient newly diagnosed with diabetes is appropriate to delegate to an unlicensed assistive personnel?

Which assessment at the beginning of the shift of the patient with a recent head injury requires the most immediate action?

The patient is rushed into the emergency department by a family member who states the patient is having a stroke. Which action does the nurse take first?

After receiving report, which patient does the nurse see first?

A fire develops in the nurses’ station kitchen. Which action does the nurse take first?

The nurse learns the patient has a plan to kill as many people as possible by stabbing or shooting them. Which intervention by the nurse is most important?

The off-duty nurse passes a car accident. Which statement is true regarding this situation?

Which statement by the unlicensed assistive personnel (UAP) indicates an understanding of the proper way to transfer patients?

Which is an example of the mitigation phase of disaster planning?

The 8-year-old presents with a generalized rash. The patient's mother reports that some areas of the rash have developed into pimples that are oozing clear fluid. The nurse places this patient on which type of precaution(s)? Select all that apply.

The novice nurse is transferring a patient from the floor to the intensive care unit. Which statement, if made by the novice nurse, indicates a need for further teaching about SBAR (Situation, Background, Assessment, Recommendation) communication?

Which action by the intensive care unit (ICU) nurse is most appropriate following the resolution of an active shooter emergency in the emergency department?

Which patient requires the most immediate attention?

The patient presents to the emergency department after having a metal beam fall on his head at a work site. He was wearing a helmet which broke with the impact. He was unconscious at the scene but is awake now, and his initial assessment is completely benign. Which finding upon reassessment 30 minutes later is most concerning?

The 15-year-old patient is hospitalized after harming herself when her mother would not let her use her cell phone. While she is awaiting inpatient psychiatric placement, she repeatedly expresses a desire to leave. Which intervention is most helpful to prevent the patient from eloping?

Which complication is of greatest concern for the patient with nephrotic syndrome?

The nurse receives report on a 76-year-old patient who is recovering from surgery for creation of an ileal pouch-anal anastomosis. The nurse plans care to prevent which complication that is most specific to this patient?

The neonate is diagnosed with purpura fulminans. Which order does the nurse anticipate first?

The nurse notes the patient is oozing blood from the IV site and has black, tarry stools. Which order will be most helpful for this patient?

The urine output of a 40-year-old male patient with a urethral catheter has decreased from 80 mL/h to 15 mL/h. Which action should the nurse take first?

The registered nurse asks the unlicensed assistive personnel to obtain the patient’s vital signs and to assist the patient to ambulate in the hallway. Which term is used to describe this nursing function?

Place the nursing interventions for a 16-year-old patient in the hospital for severe malnutrition and depression with a history of falls in order from highest priority to lowest priority.

Which nursing intervention is the highest priority for the patient admitted with a chronic obstructive pulmonary disease (COPD) exacerbation?