Delegation, Prioritization and Leadership

The patient is brought to the emergency department following a serious motor vehicular accident (MVA). List the assessments the nurse performs in order from highest to lowest priority.

The emergency department nurse is assessing the unconscious patient following a fall from the ladder while he was doing home improvement work. Which assessment is performed first?

The nurse is the first responder to a motor vehicular accident involving the injury of a 40-year-old male. Which action is the highest priority?

The nurse is involved in a motor vehicular accident in which a minor injury from the seatbelt was sustained. Which action does the nurse take first in helping the other victims?

The nurse learns that a fellow nurse is viewing the electronic chart of a patient with whom she went to high school. Which action does the nurse take first?

The nurse delegates a pre-prandial blood sugar check to the unlicensed assistive personnel who fails to perform it before the patient’s food tray arrives and the patient eats breakfast. Who is most at fault?

As instructed by the registered nurse, the unlicensed assistive personnel (UAP) obtained vitals on a patient. The UAP obtained and charted the following vital signs monitoring results: blood pressure 90/42 mm Hg, pulse 128 bpm, oxygen saturation 86% on room air, and temperature 38.2°C. (100.8°F). The UAP left the floor for a break after charting the results, but did not tell the nurse. Thirty minutes later the patient is found unresponsive and a code blue is initiated. Who is responsible for this patient’s deterioration of condition?

Which task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

The nurse is assigned to care for a patient who speaks minimal English but is fluent in Farsi. Which is the best practice for the nurse to take when communicating with this patient?

A medical-surgical floor nurse is asked to float to the intensive care unit (ICU) to alleviate understaffing. Which reason for refusing the assignment is legal?

A hospital administrator requests access to the medical record of a patient with a terminal illness for a quality review project. Which action does the nurse take?

A nurse suspects that a co-worker is abusing drugs and is under the influence while at work. Which action does the nurse take?

The nurse has just assisted an elderly client safely back into bed after a fall, and it has been determined by the nurse and the provider that no injury is present. After submitting an incident report form, which nursing action is the priority?

The nurse attempts, but is unable, to contact the provider to clarify a prescription that is much higher than the normal dosage. Which action by the nurse is appropriate?

Which term is used to describe the delivery system of nursing in which the nurse is assigned to a set of tasks delegated by the charge nurse?

The nurse assumes responsibility for developing the patient’s plan of care and for delegating works assignments. Which term describes this system of nursing?

The nurse is assigned to care for a diabetic patient with a non-healing leg wound. Which task does the nurse delegate to an unlicensed assistive personnel?

The nurse is asked to serve on a committee to determine what the available community resources are to care for infants, older adults, the disabled, and individuals with chronic health problems in the event of a natural disaster. These efforts are described as which disaster management phase?

Which patient is triaged as first to be treated following a hurricane?

The patient is brought to the emergency department following an accident with significant burns. The patient is conscious and alert with 3rd-degree burns over 50% of his body. The nurse helps to get a history and perform a thorough physical examination of this patient. Which type of assessment is the nurse performing?

The nurse is helping to ambulate a patient who is recovering from hip surgery and is a fall risk. An unlicensed assistive personnel (UAP) tells the nurse that another one of her assigned patients is in severe pain and requires pain medication. Which is the most appropriate action?

Which is the most appropriate patient assignment to assign to an unlicensed assistive personnel (UAP)?

The charge nurse is making patient assignments for an unlicensed assistive personnel, a registered nurse, and a licensed vocational/practical nurse. Which patient is the most appropriate assignment for the LVN/LPN?

Which type of fire extinguisher does the nurse use to extinguish a fire that started in an electrical outlet?

The patient with neurosyphilis who has attempted to stab the nurse with scissors, pulled out several IVs, and is a fall risk is placed in wrist restraints per physician order. How frequently does the nurse assess the patient’s skin integrity?

The nurse is called to the hospital to assist in caring for patients brought to the hospital following a massive gas explosion in the community. Which statement is true regarding the nurse’s involvement with this incident?

The nurse is supervising the care of a patient with a wound infected with methicillin-resistant staphylococcus aureus (MRSA). Which action by the student nurse would prompt the nurse to intervene?

The nurse is supervising the care of a diabetic patient with stomach cancer. After surgery, the patient is placed on total parenteral nutrition (TPN). Which information does the nurse provide the nursing student about the TPN?

To which patient does the nurse most likely anticipate administering total parenteral nutrition (TPN)?

Which task is most appropriate for the registered nurse to delegate to an unlicensed assistive personnel?

Which patient must be triaged for emergency department care first?

You are taking care of a 24-year-old with chest pain. While you are assessing him he suddenly becomes limp and unresponsive. Which action does the nurse take first?

Which nursing intervention will be most effective in preventing the spread of Clostridium difficile between patients?

The patient is pale and dizzy following a gunshot wound to the groin. Minimal bleeding is noted at the site. Vital signs are notable for a heart rate of 125 bpm and a blood pressure of 73/39 mm Hg. Two unsuccessful attempts have been made to establish an IV site. He loses consciousness. Which action does the nurse take next?

Which assessment finding in a patient complaining of back pain requires immediate action?

An 84-year-old patient being treated for a chronic obstructive pulmonary disorder (COPD) exacerbation starts to become disoriented after the evening meal and will not stay in bed. Which intervention does the nurse take first?

Which interventions does the nurse implement for the patient diagnosed with Clostridium difficile? Select all that apply.

The patient is brought to the emergency room by her husband with slurred speech and facial drooping. Which question does the nurse ask first?

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

Which patient does the nurse assess first following shift change report?

The 50-year-old patient receiving chemotherapy for breast cancer has developed a fungal bloodstream infection. Which intervention is the nurse’s first consideration?

The G2P1 patient who is 33 weeks pregnant is brought via ambulance to the emergency department due to significant vaginal bleeding and abdominal pain. Which action does the nurse take first?

The nurse is supervising the student nurse passing medications on the medical surgical floor. The nurse allows the patient to continue after which verbalization to the patient? 

The nurse is caring for a patient receiving total parenteral nutrition (TPN). After morning rounds, the nurse notices the rate of TPN infusion is slower than what is ordered for the patient and is three hours behind schedule. There are no nursing notes, and the rate was not mentioned on sign-out. Which initial action is most appropriate?

Which generation is known for being team-oriented, hardworking, efficient multi-taskers, and respectful of authority?

The student nurse accidentally administered morphine sulfate (Avinza) to the wrong patient. Who is directly accountable for the student nurse's medication error?

In regard to delegating assignments, which term refers to a reliable performance of the task?

Which term refers to the legal liability that remains with the nurse who delegates a task to an unlicensed assistive personnel?

Which component of quality improvement in medical institutions requires the institution provides standard care for all patients?

The provider is obtaining consent from the patient in preparation for a laparoscopic ureterolithotomy. The nurse witnesses the provider dismissing the patient’s questions and repeatedly asking the patient to sign the consent form. The nurse reports which violation to the charge nurse for further management?