Delegation, Prioritization and Leadership

The nurse notices that the patient’s peripheral IV insertion site is red and indurated. What action does the nurse perform first?

The patient with a history of epilepsy has a seizure in the emergency department. He has stopped convulsing, but cannot be aroused. Once the patient is admitted to a room, the patient then starts convulsing again. Which action by the nurse is appropriate?

A multidisciplinary team has been assembled to treat the patient who is hospitalized for a diabetic foot ulcer. Adherence to treatment, lifestyle, and dietary strategies has been an ongoing issue. The team includes an endocrinologist, primary care physician, a podiatrist, a registered nurse, and a dietitian. The addition of which provider to the multidisciplinary team will most positively impact outcomes for this patient?

The nurse receives shift report on four patients. Which patient does the nurse see first?

The nurse know which statement best describes a multidisciplinary team?

The registered nurse is caring for a 48-year-old patient with a surgical wound infected with methicillin-resistant Staphylococcus aureus (MRSA) requiring q6h intravenous antibiotic infusions and dressing changes twice per shift. The patient with which diagnosis is most appropriate to be added to this nurse’s assignment?

The charge nurse is planning room assignments during an outbreak of Shiga toxin-producing Escherichia coli (STEC). Due to the influx of patients, only one private room is available. Which patient with STEC must be placed in this private room?

The nurse performed a procedure for which a mask with face shield, shoe covers, and gloves were required. Place the actions of the nurse after the procedure in the correct order.

The charge nurse is making patient assignments for the unit, including one patient with disseminated varicella zoster virus infection. Which question is most important to ask the nurses when making assignments?

The neonate is diagnosed with congenital parvovirus. The nurse requests an order for which transmission prevention precaution?

A patient with signs and symptoms of cardiac chest pain arrives in the ED. Which ECG rhythm is most worrisome and requires emergent intervention?

The 6-month-old patient is admitted to the pediatric intensive care unit for treatment of a pertussis infection. The donning of which personal protective equipment by the unlicensed assistive personnel (UAP) entering this patient’s room would prompt the nurse to intervene and provide additional education?

Which patient statement is most appropriate to report to the social worker?

The nurse is caring for the patient who was admitted to the hospital in septic shock due to Escherichia coli bacteremia. Which patient assessment is most appropriate to report to the inpatient pharmacist on the patient’s medical team?

The patient admitted with asthma is receiving beclomethasone HFA PRN and nebulized albuterol PRN. Which patient assessment is most appropriate to report to the respiratory therapist assigned to care for the patient?

The patient tells the nurse, “When is Sally working again? She has been my favorite nurse so far.” Which response by the nurse is appropriate?

The provider left a patient’s electronic health record (EHR) open on the computer screen in the nurse’s station when he left to assess a patient. Which action by the nurse is most appropriate?

The patient receiving patient-controlled analgesia (PCA) with morphine is found to be sleeping deeply and minimally responsive. Which action does the nurse take first?

The LPN/LVN informs the supervising RN, “I didn’t realize until after administering the medication, but I was supposed to give the patient a half tablet of levothyroxine; I gave him a whole tablet.” Which action does the nurse take first?

The patient intubated in the intensive care unit has the following arterial blood gas results: pH 7.21 PCO2 51 PaO2 38 HCO3 16 Base Excess -7 Which action does the nurse take first?

Which arterial blood gas result is most indicative that the intubated and mechanically ventilated patient is ready to have the ventilator rate weaned?

The 3.2 kg patient with persistent pulmonary hypertension of the newborn (PPHN) has the following order: Infuse norepinephrine 0.05 mcg/kg/min IV and titrate q15 minutes by 0.05 mcg/kg/min to maintain mean arterial pressure between 45 and 55 mm Hg. Overnight, the norepinephrine had been titrated to 0.25 mcg/kg/min for persistent hypotension. At 0900, the MAP rose to 62 mm Hg and the nurse decreased the infusion from 0.25 mcg/kg/min to 0.20 mcg/kg/min. At 0905, the patient’s blood pressure fell to 42 mm Hg. Which action does the nurse take first?

The full-term neonate (3.2 kg) born precipitously to a mother of unknown infectious disease status has had a positive rapid plasma reagin (RPR) test. The nurse plans care to perform which intervention first?

Which patient on the surgical floor is at the greatest risk for abdominal wound dehiscence?

Which patient is at highest risk for skin breakdown?

The nurse changes the dressing of the patient with a sacral pressure injury. Upon removal of the dressing, the nurse notes yellow drainage on the dressing with a fruity odor. Place the nurse’s actions in the correct order from first to last.

To which team member does the registered nurse delegate a fecal occult blood test for the patient who requires assistance to ambulate to the restroom?

During routine tracheostomy cleaning and care, the nurse notes a strong smell of dirty gym socks coming from the dressing around the stoma. Which action by the nurse is most appropriate?

Which patient does the nurse assess first?

The patient is being transferred from a nursing home to an acute care facility. The receiving nurse performs which actions during the medication reconciliation process? Select all that apply.

A patient with gram-negative sepsis is in the ICU after cardiac arrest. He requires a vasopressor for severe hypotension. Which patient characteristic would prompt the nurse to hold the infusion and contact the provider?

The physician writes an order for diphenhydramine 250 mg PRN for sleep. Which part of the order does the nurse question?

The nurse makes which patient top priority?

The nurse is supervising the care of the patient who is alert but has increased intracranial pressure following head trauma. Which action by the unlicensed assistive personnel (UAP) prompts the nurse to intervene immediately?

The patient with severe asthma is found to be pale, diaphoretic, and agitated. Which assessment is most concerning?

The patient receiving inhaled nitric oxide (iNO) for severe pulmonary hypertension experiences an abrupt decrease in oxygen saturation. Which action does the nurse take first?

The nurse volunteers to be on the quality improvement team examining shift change safety and patient satisfaction. Which is the best suggestion for this quality improvement project?

The nurse receives report at the beginning of the shift. Which task is appropriate to delegate to the unlicensed assistive personnel?

Which patient does the emergency department nurse assess first?

Two days after an abdominal surgery, the patient develops abdominal distention, tachycardia, fever, and nausea. The provider suspects sepsis. Which order does the nurse implement first?

The patient receiving a continuous hydromorphone infusion for severe cancer pain is found to be unconscious with a respiratory rate of 7 breaths per minute. Which action does the nurse take first?

The nurse has received an update from the unlicensed assistive personnel about four patients. Which patient does the nurse assess first?

The patient is recovering from a lower spinal cord injury that has resulted in paraplegia and lack of sensation below the umbilicus. Which instruction is most important to help the patient protect skin integrity?

The patient has right-sided hemiplegia following a cerebrovascular accident. Interventions to prevent which complication are the priority of care?

The patient being treated for a skin wound and cellulitis is in a semi-private room with another patient; the hospital is near capacity. The culture of the wound has grown methicillin-resistant staphylococcus aureus. Which action is most appropriate? 

The nurse does not administer a physician-ordered medication because it is contraindicated for the patient. This is an example of which principle?

After a mass casualty event, the nurse triages care of dozens of patients in the emergency department (ED) based on the severity of their injury and likelihood of survival. This is an example of which principle?

Which respiratory assessment in the infant prompts the nurse to alert the provider immediately?

The nine-month-old infant appears to be in distress. For rapid assessment, which pulse does the nurse palpate?

The patient with a central venous catheter develops substernal chest pain, hypotension, and cough. There is evidence of air in the line. Which action does the nurse take first​?