NACE Management of Care 2 — Questions and Answers
Question 1: A registered nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task is appropriate to delegate?
- Initial patient assessment
- Teaching a patient about new medications
- Measuring and recording vital signs on a stable patient (Correct answer)
- Evaluating the effectiveness of a pain medication
Correct answer: Measuring and recording vital signs on a stable patient
Measuring vital signs on a stable patient is within the UAP's scope of practice. Assessment, teaching, and evaluation are nursing responsibilities that cannot be delegated.
The five rights of delegation guide appropriate task assignment: Right Task, Right Circumstance, Right Person, Right Direction/Communication, and Right Supervision. UAPs can perform routine tasks such as vital signs, I&O measurement, ambulation, bathing, and feeding on stable patients.
Question 2: During a disaster, which triage category receives treatment first?
- Black tag: deceased or expected to die
- Red tag: immediate, life-threatening conditions (Correct answer)
- Yellow tag: delayed, serious but not immediately life-threatening
- Green tag: minor injuries, can wait
Correct answer: Red tag: immediate, life-threatening conditions
Red-tagged patients have life-threatening but treatable conditions and receive the highest priority for treatment in disaster triage.
The START (Simple Triage and Rapid Treatment) system is the most widely used mass casualty triage method. Red (Immediate): life-threatening conditions requiring immediate intervention but expected to survive. Yellow (Delayed): serious injuries that can wait. Green (Minor): walking wounded. Black (Expectant/Deceased): injuries incompatible with survival.
Question 3: A nurse receives shift report on four patients. Which patient should the nurse assess first?
- A patient 1 day post-appendectomy requesting pain medication
- A patient with COPD whose oxygen saturation dropped from 92% to 84% (Correct answer)
- A patient with a urinary tract infection running a temperature of 100.4 degrees Fahrenheit
- A patient scheduled for discharge awaiting medication teaching
Correct answer: A patient with COPD whose oxygen saturation dropped from 92% to 84%
The COPD patient with rapidly declining oxygen saturation represents the most acute change in condition requiring immediate assessment using the ABCs of prioritization.
Prioritization follows the ABCs (Airway, Breathing, Circulation) and Maslow's hierarchy. The COPD patient with SpO2 dropping from 92% to 84% represents an acute respiratory decompensation that could quickly become life-threatening.
Question 4: Which communication technique is recommended for nurse-to-nurse handoff reports?
- Unstructured narrative storytelling
- SBAR format (Correct answer)
- Written notes left at the bedside
- Text message summaries
Correct answer: SBAR format
SBAR (Situation, Background, Assessment, Recommendation) is the standardized communication framework recommended by The Joint Commission for handoff reports.
SBAR was adapted from the military and aviation industries for healthcare. Situation: identify yourself, the patient, and the current issue. Background: relevant history and treatments. Assessment: your clinical assessment. Recommendation: what you think needs to happen next.
Question 5: A nurse discovers that a patient's advance directive conflicts with the family's wishes regarding end-of-life care. What is the nurse's primary role?
- Follow the family's wishes since they are present
- Advocate for the patient's documented wishes in the advance directive (Correct answer)
- Defer the decision to the attending physician
- Request an ethics committee consultation as the first action
Correct answer: Advocate for the patient's documented wishes in the advance directive
The nurse's primary role as patient advocate is to ensure the patient's documented wishes in a valid advance directive are honored, even when family disagrees.
The nurse serves as the patient's advocate, ensuring that documented wishes are respected. A valid advance directive represents the patient's autonomous decision made while competent and legally takes precedence over family wishes.
Question 6: What is the purpose of a root cause analysis (RCA) following a sentinel event?
- To assign blame to the individual responsible
- To identify system-level factors that contributed to the event and prevent recurrence (Correct answer)
- To determine the financial impact of the error
- To terminate the employment of staff involved
Correct answer: To identify system-level factors that contributed to the event and prevent recurrence
Root cause analysis is a systematic process to identify underlying system factors that contributed to an adverse event, aiming to implement changes that prevent recurrence.
Root cause analysis (RCA) is a structured methodology required by The Joint Commission following sentinel events. The process involves assembling a multidisciplinary team, mapping events, identifying contributing factors at the system level, and developing corrective action plans.
NACE Management of Care 2
A registered nurse is delegating tasks to unlicensed assistive personnel (UAP).
Which task is appropriate to delegate?