BSN Prioritization, Delegation, and Assignment 2 — Questions and Answers
Question 1: A nurse is caring for four patients. Which patient should the nurse assess FIRST using the ABCs framework?
- A patient with a blood glucose of 200 mg/dL
- A patient with oxygen saturation of 88% on room air (Correct answer)
- A patient requesting pain medication for a headache rated 5/10
- A patient who needs discharge teaching before going home
Correct answer: A patient with oxygen saturation of 88% on room air
An oxygen saturation of 88% indicates hypoxia and is an immediate airway/breathing emergency that takes priority over the other concerns.
Question 2: Which action by a nursing assistant (NA) during morning care requires the RN to intervene immediately?
- The NA assists the patient to the bathroom using a gait belt
- The NA performs oral care on an unconscious patient with the head of bed flat (Correct answer)
- The NA obtains a routine blood pressure on a stable patient
- The NA records the patient's oral fluid intake on the I&O sheet
Correct answer: The NA performs oral care on an unconscious patient with the head of bed flat
Performing oral care with the head of bed flat on an unconscious patient creates a high aspiration risk and requires immediate intervention.
Question 3: A charge nurse is assigning patients. Which patient is MOST appropriate to assign to a newly licensed RN still on orientation?
- A patient with a new tracheostomy requiring suctioning every 2 hours
- A patient post-op day 2 following an appendectomy with stable vital signs (Correct answer)
- A patient in alcohol withdrawal showing early signs of delirium tremens
- A patient receiving a continuous heparin drip for pulmonary embolism
Correct answer: A patient post-op day 2 following an appendectomy with stable vital signs
A stable post-op day 2 appendectomy patient represents a predictable, lower-acuity assignment appropriate for a nurse still building clinical competency.
Question 4: Under which circumstance is it appropriate to delegate a task to a licensed practical nurse (LPN)?
- Performing the initial nursing assessment on a newly admitted patient
- Administering a routine oral medication to a stable patient (Correct answer)
- Developing a patient's individualized care plan
- Evaluating the patient's response to a new pain management protocol
Correct answer: Administering a routine oral medication to a stable patient
Administering routine medications to stable patients is within the LPN scope of practice in most states and is an appropriate delegation.
Question 5: A nurse uses the SBAR communication tool when handing off a deteriorating patient. What does the 'R' stand for?
- Report
- Recommendation (Correct answer)
- Review
- Response
Correct answer: Recommendation
In SBAR, 'R' stands for Recommendation — the nurse's suggested action or plan for addressing the patient's condition.
Question 6: Which of the following tasks CANNOT be delegated to an unlicensed assistive personnel (UAP) by an RN?
- Measuring and recording urine output
- Ambulating a stable postoperative patient in the hallway
- Performing a focused respiratory assessment on a patient with new-onset shortness of breath (Correct answer)
- Obtaining a routine set of vital signs on a stable patient
Correct answer: Performing a focused respiratory assessment on a patient with new-onset shortness of breath
Assessment is a cognitive, clinical judgment task that falls exclusively within the RN scope of practice and cannot be delegated to UAP.
Question 7: A nurse is prioritizing care using Maslow's Hierarchy of Needs. Which patient need should be addressed first?
- A patient who feels isolated and wants visitors
- A patient with acute urinary retention causing significant pain and bladder distension (Correct answer)
- A patient who is anxious about an upcoming surgery scheduled for tomorrow
- A patient who requests a specific type of pillow for comfort
Correct answer: A patient with acute urinary retention causing significant pain and bladder distension
Acute urinary retention is a physiological need causing physical harm and must be addressed before psychological or comfort needs.
BSN Prioritization, Delegation, and Assignment 2
A nurse is caring for four patients.
Which patient should the nurse assess FIRST using the ABCs framework?