Delegation, Prioritization and Leadership

The nurse is preparing for the insertion of a peripherally inserted central catheter (PICC). Which action prompts the nurse’s orientee to clarify sterile technique?

The nurse is setting up the sterile field for a sterile dressing change. A sterile gauze 4x4 falls with the corner 2 cm from the sterile field. Which action by the nurse is most appropriate?

The nurse is setting up a sterile field for the provider to insert a chest tube. The nurse drops the scissors onto the field where they land with the tip 2 inches from the edge. Which action by the nurse is most appropriate?

The operating room nurse is supervising the orientee circulating nurse who has been asked to pour sterile saline into the sterile tray. Which action(s) by the nurse prompt the supervising nurse to provide additional education? Select all that apply.

After reviewing the patient’s chart, which order(s) require clarification? Review the patient’s chart, then select all that apply.

A fire breaks out on multiple floors of the hospital and the charge nurse has been instructed to evacuate the patients. In which order are the patients evacuated?

The nurse is creating a tool to screen for patients who are risk for vitamin A deficiency. The nurse includes which conditions in the screening tool? Select all that apply.

The registered nurse on the medical-surgical floor is delegating tasks to an unlicensed assistive personnel, certified medication assistant, and a licensed practical/vocational nurse. Which task does the nurse delegate to the LPN/LVN?

The 2-day-old full term child has been rooming in with the mother who reports successful breastfeeding. Which information is most important to report to the provider?

The nurse has observed the resident physician move between patients without performing hand hygiene on multiple occasions. Each time, the nurse asks the resident physician to perform hand hygiene before moving on to the next patient; the resident physician scoffs at the nurse and continues examining patients. Which action by the nurse is most appropriate?

The nurse is supervising the care of a patient with a stage II pressure injury on the coccyx. Which intervention by the student nurse prompts the nurse to intervene with further education?

Following an apartment fire, the patient is brought to the emergency department by ambulance. The patient has third degree burns on the anterior bilateral lower legs and thighs, abdomen, and anterior bilateral arms. Soot is noted on the face; the patient appears to be speaking normally. Place the actions in the order the nurse performs them.

Following an explosion at a factory, the patient is brought by ambulance to the emergency department. The patient has soot on the face and around the mouth and is coughing up black sputum. He verbalizes severe pain in his leg and his voice is noted to be a hoarse whisper. Further assessment reveals full thickness burns to the arms and hands and partial thickness burns to the legs. Shrapnel appears to have been embedded in the patient’s thigh. While moving the leg to assess the inner thigh, a piece of shrapnel shifts and the patient begins bleeding profusely from the wound. The patient cries out in pain and requests pain relief. Which action does the nurse take first?

The nurse is planning care for a patient who sustained third degree burns over 42% of the body during an industrial accident the previous day. The patient is intubated, sedated, and chemically paralyzed. Which patient problem is most important for the nurse to address?

The patient sustained third degree burns to the entirety of bilateral hands and forearms 96 hours ago. Which nursing intervention is most important to ensure the patient is able to keep the hands?

The 32-year-old female patient (60 kg) is brought via ambulance to the emergency department following a water drinking competition. The patient has a Glasgow Coma score of 6, oxygen saturation of 94% on room air, heart rate of 62 bpm, and respiratory rate of 16 breaths per minute. The nurse anticipates administering which medication?

The nurse is supervising the unlicensed assistive personnel (UAP) in the care of the patient who underwent surgical therapy for lung cancer in the right lower lobe one day prior. Which patient positions, if helped into by the UAP, prompt the nurse to intervene and provide additional education? Select all that apply.  

At 48 hours after a bowel resection surgery for colon cancer, the colostomy is noted to be moist and purple. Which additional assessment is most important?  

The nurse most closely monitors the temperature for the patient who underwent which procedure?  

The 62-year-old male patient presents to the office complaining of difficulty urinating, with a weak stream, waking multiple times in the night to urinate, and the feeling of not completely emptying the bladder that has been occurring for months. Which test must be performed first for this patient? 

The 3-year-old patient with acute pyelonephritis has the following orders:  Medications: 8 mg/kg ciprofloxacin IV q8h  Activity level: ambulatory as tolerated  Intravenous fluids: Infuse D5W with 0.25% NaCl via peripheral IV at 50 mL/h  Diet: Normal   The nurse is coordinating care for the patient with the unlicensed assistive personnel. Which statement by the UAP prompts further education by the nurse? 

The nurse is supervising a nursing student in the emergency department. Which actions by the nursing student indicate effective learning? Select all that apply.  

The patient who was started on warfarin sodium for the treatment of atrial fibrillation has reached steady state with the current dose. Which instruction is most important to give the patient?

The patient is scheduled for a liver biopsy tomorrow. The nurse has difficulty obtaining blood specimens from the patient and can only send one lab. Which lab test does the nurse choose? 

The patient on bowel rest has been prescribed 10% dextrose total parenteral nutrition at 50 mL/h, intravenous lipids 3 grams/kg/day, and 10 mg intravenous famotidine every other day. Which information in the patient’s chart prompts the nurse to contact the provider? 

The 21-year-old patient with a body mass index of 10.1 undergoes placement of a peripherally inserted central catheter (PICC) at 1000 and total parenteral nutrition (TPN) is initiated at 1200. At 1600, 160 mL have infused and the patient is noted to be breathing shallowly, there is blood oozing from the PICC insertion site, and the patient is exhibiting confusion. Which action does the nurse perform first? 

The nurse is supervising the student nurse in performing a cap change for a peripherally inserted central catheter (PICC) in a patient who recently sustained a traumatic brain injury. Which action by the student nurse best indicates effective learning?

At the beginning of the shift, the nurse assesses the patient receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter and notes a crack in the tubing with TPN leaking. The nurse notifies the provider and anticipates receiving which order first? 

The nurse is caring for a patient in the intensive care unit with breast cancer who has a radiation implant in the right breast. The patient is also receiving a chemotherapy regimen. Which additional patient is most appropriate to be assigned to the nurse?

The nurse assesses the patient with acute myelogenous leukemia after a bone marrow transplant. Which symptom concerns the nurse the most?

The nurse is selecting patients to receive a brochure about detecting testicular cancer. Which patient most needs the brochure? 

The patient’s activated partial thromboplastin time (aPTT) is 138 seconds. Review the chart to determine the most important question for the charge nurse to ask the bedside nurse.

The nurse provides which instructions to the unlicensed assistive personnel who is assisting in the care of a patient postoperative day one following a radical hysterectomy? Select all that apply. 

Which intervention is most important for the 38-week-gestation neonate who was antenatally diagnosed with hypoplastic left heart syndrome and born 2 hours ago?  

The nurse in a tertiary medical center with attached pediatric hospital is caring for the 28-year-old gravida 3 para 2 woman who is 40-weeks pregnant and presents to the labor and delivery unit 1 hour after spontaneous rupture of membranes. Patient had good prenatal care, an amniotic fluid index of 12, and pregnancy is complicated only by the antenatal diagnosis of fetal single ventricle anatomy.  Labor is progressing well and the fetus is tolerating contractions well with moderate variability in fetal heart tones. The nurse is most concerned with having which item in the delivery room? 

The nurse is caring for the patient recently diagnosed with colon cancer. Which assessment prompts the nurse to call for the provider immediately?  

The patient is brought to the emergency department following a gunshot wound to the right chest. The patient is noted to have tracheal deviation to the left side with absent breath sounds on the right. Review of the chest radiograph indicates a large amount of free air in the superior chest as well as fluid in the inferior chest. Which procedure is performed first? 

The 13-year-old patient presents to the emergency room following a sports practice in the late summer heat with severe joint pain, malaise, splenomegaly, tachypnea, and tachycardia. Upon assessment, the patient’s oxygen saturation is 92%. Which order does the nurse carry out first?

The patient is brought to the emergency department complaining of sudden onset crushing substernal chest pain. He is pale, diaphoretic, and can only speak in short sentences. His vital signs are notable for a heart rate of 118 bpm, respiratory rate of 22, and a blood pressure of 94/52 mmHg. Upon assessment, peripheral pulses are palpable but weak; lungs are clear; mild jugular venous distention is noted. The emergency medical services administered aspirin on arrival to the scene. The nurse anticipates performing which intervention first? 

The 72-year-old patient is brought via the ambulance to the emergency department after his wife observed him collapsing after dinner. At the scene, emergency medical service (EMS) personnel determined he was in asystole, and began cardiopulmonary resuscitation (CPR). An advanced airway was placed and a peripheral intravenous catheter was inserted. The defibrillator was placed and read ventricular fibrillation; a shock was administered, chest compressions were restarted, and a 1 mg epinephrine dose was administered via peripheral IV. Upon arrival to the emergency department, the patient was found to be in pulseless electrical activity after 5 complete rounds of CPR (including epinephrine, defibrillation, and 30:2 chest compressions to ventilated breaths ratio). The nurse advocates for which intervention?

The 1-year-old with sickle cell disease is in crisis following gastroenteritis. While hospitalized, the patient abruptly exhibits seizures, decreased level of consciousness, right-sided facial asymmetry when crying, coughing and sputtering during a bottle feeding, and decreased movement of the right leg and arm. The nurse contacts the provider and prepares to provide which initial interventions? Select all that apply.  

The 8-year-old male patient presents complaining of warm, painful, swollen joints with decreased range of motion. Upon assessment, he is pale and tachycardic. The parent reports easy bruising and frequent nosebleeds. Which does the nurse most anticipate administering? 

The nurse is providing discharge teaching to the parents of the 3-year-old patient who was recently diagnosed with type 1 diabetes mellitus. Which item, if identified by the parents as the most important item to carry at all times, indicates effective teaching?  

The patient in the emergency department begins projectile vomiting. Which intervention is most important?  

The nurse is supervising the assessment of a 4-year-old patient with a Wilms tumor who was brought to the emergency department for profuse vomiting. Which statement by the student nurse requires prompt intervention by the nurse? 

The nurse is preparing to care for a baby antenatally diagnosed with type C esophageal atresia with tracheoesophageal fistula. Which interventions are the priority in the first day after birth?  

The patient receiving chemotherapy for breast cancer develops a fever of 39.8°F and heart rate of 121 bpm. Within hours, the blood pressure drops from 128/89 mmHg to 91/54 mmHg, capillary refill time increases to 5 seconds, and urine output drops to less than 0.5 mL/kg/hour. Right-sided weakness, slurring of the words, and confusion occurs rapidly and subsides within 2 hours. Hemoptysis is also noted and the gums are oozing. Multiple transfusions are ordered. Which blood product does the nurse administer first?

The nurse overhears a colleague preparing a dose of naltrexone. The nurse offers to assist and ensures the colleague takes which actions? Select all that apply.  

The 71-year-old patient with a history of hypertension, hypercholesterolemia, and type 2 diabetes mellitus is brought to the emergency department 3 hours after exhibiting right-sided facial weakness, drooping of the right eye, and slurring of the words. Appendicular tone is normal and the patient has no issues walking or standing from a sitting position. The nurse prepares the patient for which intervention first? 

The 11-month-old, previously healthy infant is brought to the emergency department after becoming increasingly lethargic over the past 24 hours. The infant’s vital signs are notable for a temperature of 40.8°C, heart rate 138 bpm, respiratory rate 31, and blood pressure 84/50 mmHg. Upon assessment, the nurse notes sensitivity to light and sound, bulging anterior fontanelle, and significant resistance to turning the head. Place the interventions in the correct order.