Delegation, Prioritization and Leadership

The nurse is caring for a 57-year-old woman who is intubated and sedated in the post-anesthesia care unit following a radical hysterectomy. The patient remained stable throughout the 6 hour surgery during which she experienced a 2 L blood loss. The nurse has emptied the patient’s indwelling catheter every hour for the 3 hours the patient has been in the PACU with the following volumes: 54 mL, 23 mL, 12 mL, and 5 mL. Her heart rate is 112 bpm, oxygen saturation is 99%, and blood pressure is 82/54 mmHg. The nurse contacts the provider to report these findings and advocate for which initial order?  

The 5-day-old 38-week-gestation neonate was born to a 25-year-old primigravida woman after a pregnancy and vacuum-assisted delivery complicated by gestational diabetes, large for gestational age fetus, and shoulder dystocia. The neonate required vigorous stimulation and positive pressure ventilation. Apgar scores were 3 and 8 at 1 and 5 minutes of life. At the pediatrician’s appointment after discharge, the neonate is found to have a large bruise at the back of the head that was sustained during birth and eyes glued shut with yellow, mucopurulent discharge. A gram stain of the drainage reveals gram-negative cocci in pairs. The mother states, “No matter what I do, it keeps coming back. I’ve used warm compresses and washed it away.” Additionally, the mother reports the infant is breastfeeding well with 4 wet diapers and 1 stool per day. The nurse informs the provider of the assessment and requests which order first?  

The 22-month-old child is brought to the emergency department with large, blistered burns to both buttocks by his mother’s boyfriend. The mother’s boyfriend states the child has been in his care while the mother is away on a business trip. He reports the child accidentally fell into the bath during the preparation before the water had had a chance to cool. The child’s second-degree wounds are dressed after intravenous morphine is administered. The nurse works with the healthcare team to perform which intervention? 

The 50-year-old previously healthy patient complains of shortness of breath, especially on exertion or when laying down to sleep. She takes over-the-counter allergy medicine for seasonal allergies and melatonin to help her sleep sometimes. Her vital signs are heart rate of 64 bpm, respirations 22, oxygen saturation 99%, and blood pressure 114/68 mmHg. Her assessment is notable for crackles over the bilateral lung bases and a moderate diastolic apical murmur. The nurse prepares the patient for which initial tests? Select all that apply. 

The 58-year-old patient presents to the emergency department of a community hospital complaining of worsening back pain that started a few days ago. He states, “I thought maybe I had slept wrong and gotten a spasm, but I’m not sure. I didn’t fall or get hit or anything. The ibuprofen I took definitely didn’t help.” His blood pressure is 174/96 mmHg and heart rate is 96 bpm. He reports being out of his antihypertensive medication for the past week while he was out of town. Other history is notable for arthritis in the hands and a 44-pack-year smoking history. He drinks socially but denies illicit drug use. A pulsating abdominal mass is noted; otherwise, his assessment is benign. The nurse advocates for which treatment option? 

The 28-year-old G2P1 patient presents after rupture of membranes 2 hours ago at 39 weeks gestation. She has a history of prior cesarean section for failure to progress but is otherwise healthy; this pregnancy is uncomplicated. Contractions are painful and labor is progressing. Abruptly, the patient complains of extreme abdominal pain; the nurse observes a significant amount of blood coming from her vagina. Which action is most important? 

The 28-year-old G2P1 patient presents after rupture of membranes 2 hours ago at 39 weeks gestation. She has a history of prior cesarean section for failure to progress but is otherwise healthy; this pregnancy is uncomplicated. Contractions are painful and labor is progressing. Abruptly, the patient complains of extreme abdominal pain; the nurse observes a small amount of blood coming from her vagina. Which assessment prompts the nurse to prepare the patient for an emergency cesarean section? 

The nurse witnesses a 19-year-old collapse while playing soccer. The individual is arousable but confused and irritable. The skin is warm, dry, and flushed. Which actions are most helpful? Select all that apply.  

The 20-year-old healthy soccer player is brought to the emergency department after collapsing at the end of a summer soccer game. The patient is lethargic and confused about the event. Upon assessment, the nurse notes flushed, dry skin that is warm to the touch. The oral mucosa is dry, as well. Vitals are as follows: temperature 40.7°C, heart rate 122 bpm, respiratory rate 20, and blood pressure 116/64 mmHg. Which order does the nurse carry out first?  

The 20-year-old healthy soccer player is brought to the emergency department after collapsing at the end of a summer soccer game. The patient is lethargic and confused about the event. Upon assessment, the nurse notes flushed, dry skin that is warm to the touch. The oral mucosa is dry, as well. Vitals are as follows: temperature 40.7°C, heart rate 122 bpm, respiratory rate 20, and blood pressure 116/64 mm Hg. A rectal thermistor is inserted and aggressive cooling measures are instituted. After 30 minutes in the ice bath, the patient’s rectal temperature is 39.1°C and the ice is partially melted. The nurse notes the rectal thermistor has stopped working; there are no other rectal thermistors in the facility. Which action by the nurse is most appropriate? 

The mother of the 7-week-old infant reports the baby has had fewer and fewer wet diapers and hasn’t stooled in 3 days despite having a ravenous appetite. The mother reports that the child has been vomiting with increasing force and volume over the past two weeks. The emesis just appears to be partially digested breastmilk and fluid. The infant appears well, but mucous membranes are dry, the child has a low-grade fever, and is tachycardic. Upon palpation of the abdomen, a small, olive-shaped mass is appreciated. A serum electrolyte panel reveals a sodium of 132, potassium of 2.7, chloride of 89, and a glucose of 92. The nurse performs which nursing action first? 

A nurse is nearing the end of her very busy shift. As she is about to leave she notices a nurse’s aide and LPN are playing cards in the break room. The nurse confirms they are both on shift and asks why they are playing instead of working. The LPN states they were not given any work tasks to complete. Which response from the nurse is most appropriate?

The patient has been prescribed belatacept for transplant rejection. Which lab result is most important to evaluate prior to administration?