Nursing Prioritization, Delegation and Assignment Flashcards

The high-pressure alarm on a patient’s ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next?

Answer: Manually ventilate the patient while assessing possible reasons for the high-pressure alarm

A high-pressure alarm on a ventilator, coupled with decreased oxygen saturation and patient distress, indicates an immediate and life-threatening respiratory emergency. The priority is to ensure adequate oxygenation and ventilation without delay. Manually ventilating the patient provides immediate respiratory support, bypassing the malfunctioning ventilator and allowing time to assess and troubleshoot the cause of the alarm.

The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient’s comfort for this problem?

Answer: Suggest that the patient’s oxygen be humidified

Oxygen delivered via nasal cannula, especially at higher flow rates like 6 L/min, can be very drying to the mucous membranes of the nasal passages, leading to discomfort and irritation. Humidification adds moisture to the oxygen, which helps prevent this dryness and improves patient comfort. This is a common and effective intervention for this specific problem.

The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision?

Answer: Observe how well the patient performs pursed-lip breathing

Observing a patient's technique for a learned skill like pursed-lip breathing falls within the scope of practice for an experienced LPN, as it involves data collection and monitoring an established intervention. LPNs are trained to reinforce teaching and assess patient performance of basic nursing skills. Planning comprehensive care, assisting with complex ADLs, or consulting with other departments typically requires the broader assessment and critical thinking skills of a Registered Nurse.

The patient with COPD tells the nursing assistant that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the nursing assistant to report which of these?

Answer: Oral temperature of 101.2 F (38.4C)

A temperature of 101.2 F (38.4C) indicates a fever, which is a significant sign of infection. Patients with COPD are highly susceptible to respiratory infections, and an unvaccinated status further increases this risk. Given the potential for rapid deterioration in COPD patients with infection, this finding requires immediate reporting to the RN for prompt assessment and intervention.

To improve respiratory status, which medication should you be prepared to administer to the newborn infant with RDS?

Answer: Surfactant (Exosurf)

Respiratory Distress Syndrome (RDS) in newborns is primarily caused by a deficiency of pulmonary surfactant, which is essential for reducing surface tension in the alveoli and preventing lung collapse. Administering exogenous surfactant directly addresses this physiological deficiency, improving lung compliance and gas exchange. Theophylline and Albuterol are bronchodilators, and Dexamethasone is a steroid, which are not the primary treatment for surfactant deficiency.

When a patient with TB is being prepared for discharge, which statement by the patient indicates the need for further teaching?

Answer: “I will continue to take my isoniazid until I am feeling completely well.”

Tuberculosis treatment, including isoniazid, requires a prolonged course, typically 6 to 9 months, to completely eradicate the Mycobacterium tuberculosis bacteria and prevent drug resistance. Stopping medication prematurely, even if the patient feels well, is a common cause of treatment failure and relapse. This statement indicates a critical misunderstanding of the treatment regimen and the importance of adherence.

When assessing a 22-year old patient who required emergency surgery and multiple transfusion 3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate?

Answer: Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status

The patient's symptoms (anxiety, labored respirations at 38 breaths/min, and oxygen saturation of 90% despite 6 L/min via nasal cannula) indicate severe respiratory distress and hypoxemia. A nonrebreather mask delivers the highest concentration of oxygen (up to 95-100%), providing the most immediate and aggressive respiratory support. Simultaneously, the physician must be notified for further evaluation and orders, as the patient's condition is critical.

Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team?

Answer: Auscultating the lungs for crackles

Auscultating lung sounds is a fundamental assessment skill that involves listening for specific sounds to gather objective data. This task falls within the scope of practice for an experienced LPN, as it involves data collection and monitoring. Evaluating chest pain, monitoring complex laboratory values, and assessing for symptoms of respiratory failure require a higher level of critical thinking, interpretation, and clinical judgment typically performed by an RN.

Which of these medication orders for a patient with a pulmonary embolism is more important to clarify with the prescribing physician before administration?

Answer: Warfarin (Coumadin) 1.0 mg by mouth (PO)

Warfarin is a potent anticoagulant, and a dose of 1.0 mg is unusually low for therapeutic anticoagulation, especially in a patient with an active pulmonary embolism where rapid and effective anticoagulation is crucial. This dose could be a transcription error or potentially ineffective, making clarification with the prescribing physician essential to ensure patient safety and appropriate treatment for the pulmonary embolus.

The patient being looked for by the nurse is thought to be in the beginning stages of dementia. The nurse notes some minor restlessness, short-term memory loss, and confusion. The nurse does a quick mental status examination. Which of the following critical thinking techniques is the nurse utilizing?

Answer: Interpretation

Interpretation involves making sense of observed data and drawing conclusions about its meaning. The nurse is observing specific signs (minor restlessness, short-term memory loss, confusion) and interpreting these cues as potential indicators of early dementia. This interpretation then prompts the nurse to perform a mental status examination to further validate and assess these findings.

A patient has received instructions on how to administer insulin shots on their own. As the patient tries to recap the needle, the nurse notices that more instruction is required. Which nursing critical thinking technique is the nurse using?

Answer: Analysis

Analysis in critical thinking involves breaking down information into its component parts and examining their relationships to identify patterns or problems. The nurse is observing the patient's technique for administering insulin and specifically identifying an error in recapping the needle. This detailed examination of the patient's actions to pinpoint a specific area needing correction is an example of analysis.

Examples of: Case Management, Home Health Care, Physical Therapy

Answer: collaborative interventions

Collaborative interventions are actions that require the expertise and cooperation of multiple healthcare professionals or departments to achieve patient goals. Case Management, Home Health Care, and Physical Therapy are all services provided by other disciplines that the nurse coordinates with, rather than performing independently or as a direct dependent order for a nursing action. They exemplify interdisciplinary teamwork.

Utilizing critical thinking abilities during the nursing procedure' assessment phase guarantees that the nurse

Answer: Completes a comprehensive database.

During the assessment phase, critical thinking ensures the nurse systematically and thoroughly gathers all relevant subjective and objective data from various sources. This comprehensive data collection forms the foundation for accurate nursing diagnoses, effective planning, and appropriate interventions. Without a complete database, crucial information might be missed, leading to an incomplete or incorrect care plan.

An illustration of a quantifiable objective is:

Answer: "The patient will be able to lift 10 lb by October 19th 1500."

A quantifiable objective must be specific, measurable, achievable, relevant, and time-bound (SMART). Option B clearly states a specific, measurable weight (10 lb) and a precise date and time (October 19th 1500) for achievement. This level of detail allows for objective evaluation of the patient's progress, unlike the other options which are vague or lack specific metrics.

Which of the following claims qualifies as objective data? (Check every box that applies.)

Answer: "Lung sounds clear bilaterally, diminished in right lower lobe."

Objective data are measurable and observable facts that can be perceived by the nurse through their senses or with instruments. 'Lung sounds clear bilaterally, diminished in right lower lobe' and 'Blood pressure 90/68, apical pulse 102, skin pale and moist' are both direct observations and measurements made by the nurse. The other options are subjective statements reported by the patient.

Using Maslow's hierarchy of demands, the nurse decides what medical attention a client with diabetes mellitus requires first. Which need is considered to be the client's top priority?

Answer: The nurse teaches the client how to properly change dressings on the​ right-leg amputation site.

According to Maslow's Hierarchy of Needs, physiological needs are the most basic and highest priority. Proper dressing changes for an amputation site are critical to prevent infection, promote healing, and maintain skin integrity, directly addressing a physiological need. Addressing this immediate physical need takes precedence over safety education, body image concerns, or social support groups.