Free Prioritization, Delegation, and Assignment Questions and Answers — Questions and Answers
Question 1: A 16-year-old cystic fibrosis adolescent is admitted with worsening breathlessness and potential pneumonia. Which nursing task must be included in the patient's care the most?
- Allow the patient to decide whether she needs aerosolized medications.
- Place the patient in a private room to decrease the risk of further infection.
- Plan activities to allow at least 8 hours of uninterrupted sleep.
- Perform postural drainage and chest physiotherapy every 4 hours. (Correct answer)
Correct answer: Perform postural drainage and chest physiotherapy every 4 hours.
For people with cystic fibrosis, airway clearance procedures are essential and should come first. Mucus dehydrates as a result of the Cystic Fibrosis Transmembrane Conductance Regulator deficiency. In cystic fibrosis, the secretions are typically thick, gooey, and more challenging to remove. Both the treatment of acute exacerbations and the maintenance of health in cystic fibrosis depend heavily on frequent airway clearance.
Question 2: Despite using a non-rebreather mask to deliver oxygen to a patient with acute respiratory distress syndrome (ARDS), arterial blood gas readings still indicate low oxygenation. You would anticipate a doctor's order for what action as the nurse in charge of this patient's care, wouldn't you?
- Administer furosemide (Lasix) 100 mg IV push stat.
- Call a code for respiratory arrest.
- Perform endotracheal intubation and initiate mechanical ventilation. (Correct answer)
- Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth.
Correct answer: Perform endotracheal intubation and initiate mechanical ventilation.
A non-rebreather mask can provide almost all of the oxygen needed. Refractory hypoxemia is observed when the patient's oxygenation status does not significantly improve in response to the supply of oxygen at this high dosage. The patient is typically exerting a lot of effort to breathe at this point and risking respiratory arrest unless medical professionals step in and administer intubation and mechanical ventilation to lessen the patient's labor of breathing.
Question 3: A patient suffering from chronic obstructive pulmonary disease (COPD). Which airway management procedure should a nursing assistant handle?
- Auscultation of breath sounds every 4 hours.
- Assisting the patient to sit up on the side of the bed. (Correct answer)
- Instructing the patient to cough effectively.
- Teaching the patient to use incentive spirometry.
Correct answer: Assisting the patient to sit up on the side of the bed.
The educational background and scope of practice of a nursing assistant include helping patients with positioning and activities of daily life. Under the direct supervision of the nurse, nonprofessional, unlicensed assistive nursing personnel may legally be assigned certain tasks and aspects of care, provided they are competent in those areas, such as assistance with transfers, range of motion, feeding, ambulation, and other tasks like making beds and assisting with bowel and bladder functions.
Question 4: A nursing diagnostic of sleep deprivation due to a disrupted sleep cycle is given to a patient with sleep apnea. Which task ought to you assign the nursing assistant?
- Remind the patient to sleep on his side instead of his back. (Correct answer)
- Administer modafinil (Provigil) to promote daytime wakefulness.
- Discuss weight-loss strategies such as diet and exercise with the patient.
- Teach the patient how to set up the BiPAP machine before sleeping.
Correct answer: Remind the patient to sleep on his side instead of his back.
The nursing assistant can remind patients to perform tasks that are specified in their care plan and have already been taught to them by the nurse. The appropriate person must be given the appropriate tasks and responsibilities under the appropriate conditions. Following that, the nurse who assigned the tasks and jobs must interact with and supervise the person performing them. The nurse oversees the individual and judges whether or not the task was completed in a proper, suitable, safe, and competent manner.
Question 5: The nursing assistant takes the patient's vital signs after the respiratory therapist suctions an intubated patient. Which vital sign value needs to be reported right away to the licensed nurse by the nursing assistant?
- Blood pressure of 168/90 mm Hg
- Tympanic temperature of 101.4ºF (38.6ºC) (Correct answer)
- Heart rate of 98 beats/min
- Respiratory rate of 24 breaths/min
Correct answer: Tympanic temperature of 101.4ºF (38.6ºC)
The risk of infection for a patient undergoing mechanical breathing never goes away. Bypassing the body's natural air-filtering systems, the endotracheal tube gives bacteria and viruses a direct path to the lower respiratory system.
Question 6: The ventilator of a patient sounds the high-pressure alarm. The oxygen saturation meter in the patient's room indicates 87% when you walk in to evaluate the ARDS patient, who is also having trouble sitting up. Which move ought to you make next?
- Insert an oral airway to prevent the patient from biting on the endotracheal tube.
- Reassure the patient that the ventilator will do the work of breathing for him.
- Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. (Correct answer)
- Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning.
Correct answer: Manually ventilate the patient while assessing possible reasons for the high-pressure alarm.
You can give the patient 100% FiO2 by manually ventilating them while you try to figure out what's causing the high-pressure alarm. Safe ventilation parameters for each patient and their conditions should be taken into account while using proper ventilation strategies with the BVM.
Question 7: A patient who is getting oxygen through a nasal cannula at a flow rate of 6 L/min complains of nasal passage irritation, the nursing assistant informs you. What course of action might you recommend to enhance the patient's comfort in light of this issue?
- Suggest that the patient be provided with an extra pillow.
- Suggest that the patient sit up in a chair at the bedside.
- Suggest that a simple face mask be used instead of a nasal cannula.
- Suggest that the patient's oxygen be humidified. (Correct answer)
Correct answer: Suggest that the patient's oxygen be humidified.
The mucous membranes may dry out when the oxygen flow rate exceeds 4 L/min. The best course of action is to upgrade the oxygen delivery system with humidification. For patients who need high-flow oxygen systems for longer than 24 hours or who complain of upper airway irritation owing to dryness, it is permissible to utilize humidified oxygen. It can also be beneficial to apply a water-soluble jelly to the nares to lessen mucosal irritation. None of the alternative solutions will address the issue.
Free Prioritization, Delegation, and Assignment Questions and Answers
A 16-year-old cystic fibrosis adolescent is admitted with worsening breathlessness and potential pneumonia.
Which nursing task must be included in the patient's care the most?