Nursing Prioritization, Delegation, Assignment Practice Exam Quiz

Nursing Prioritization, Delegation, Assignment Practice Exam Quiz

 

Which patient should the nurse prioritize for immediate care?

A 25-year-old with a sprained ankle
B. A 50-year-old with a history of hypertension and a headache
C. A 70-year-old with shortness of breath and chest pain
D. A 40-year-old with a mild fever and fatigue

 

Which task is appropriate for delegation to a UAP (Unlicensed Assistive Personnel)?

Administering an intravenous medication
B. Assisting a patient with bathing
C. Conducting a pain assessment
D. Educating a patient about their condition

 

When delegating a task, the nurse must ensure that:

The task is within the delegatee’s scope of practice
B. The task is completed by the nurse
C. The task is unimportant
D. The nurse is available for all tasks

 

Which patient should be assessed first in a busy emergency department?

A patient with a sprained wrist
B. A patient with a headache and nausea
C. A patient with a history of asthma and mild wheezing
D. A patient with severe chest pain and sweating

 

Which task can a nurse delegate to an LPN?

Administering a blood transfusion
B. Assessing a patient’s neurological status
C. Administering prescribed medications via oral route
D. Teaching a patient about their discharge instructions

 

What is the nurse’s priority action when a patient is in respiratory distress?

Notify the healthcare provider immediately
B. Administer oxygen as prescribed
C. Increase the intravenous fluids
D. Reassure the patient and monitor vital signs

 

Which of the following is the most important action when a nurse is prioritizing care for multiple patients?

Prioritize patients based on the severity of their condition
B. Prioritize patients based on the order of their admission
C. Prioritize patients based on age and gender
D. Prioritize patients based on their requests

 

Which of the following actions should a nurse take first when a patient is showing signs of shock?

Administer prescribed medication
B. Position the patient with legs elevated
C. Notify the healthcare provider
D. Begin fluid resuscitation as ordered

 

Which task can a nurse safely delegate to a UAP (Unlicensed Assistive Personnel)?

Assessing a patient’s pain level
B. Measuring a patient’s blood pressure
C. Teaching a patient about post-op care
D. Collecting a urine specimen

 

Which patient should the nurse assess first after receiving shift report?

A patient with a new cast on their leg and stable vital signs
B. A patient who is post-operative and asking for pain medication
C. A patient with an oxygen saturation of 92% and mild shortness of breath
D. A patient with chest pain and an elevated heart rate

 

A nurse is reviewing tasks that can be delegated to a UAP. Which of the following is appropriate?

Inserting an intravenous catheter
B. Monitoring vital signs in a stable patient
C. Performing a sterile dressing change
D. Assessing the level of consciousness

 

Which of the following should be delegated to an experienced nurse?

A patient with a mild fever and cough
B. A post-operative patient with chest tube drainage
C. A patient with a sprained ankle
D. A patient with a routine health screening

 

What is the first priority when caring for a patient with an open wound?

Apply a sterile dressing
B. Administer pain relief
C. Monitor for signs of infection
D. Assess the wound for depth and severity

 

Which action should the nurse take when delegating a task to an LPN?

Provide direct supervision for all tasks
B. Ensure the task is within the LPN’s scope of practice
C. Allow the LPN to make independent decisions
D. Delegate all assessment tasks to the LPN

 

Which patient should the nurse prioritize in the post-operative unit?

A post-operative patient with a stable vital signs
B. A post-operative patient with decreased oxygen saturation
C. A patient with a mild headache and no other complaints
D. A patient with mild nausea after surgery

 

Which of the following tasks can a nurse delegate to a UAP?

Assessing a patient’s pain level
B. Administering medication
C. Assisting with a bed bath
D. Providing patient education

 

Which of the following is the nurse’s highest priority in a triage situation?

A patient with a broken arm
B. A patient with a fever of 102°F
C. A patient with difficulty breathing
D. A patient with a headache

 

Which of the following is an appropriate task for delegation to a UAP?

Obtaining a 12-lead ECG
B. Inserting a Foley catheter
C. Taking vital signs for a stable patient
D. Performing a wound debridement

 

The nurse is delegating the task of ambulating a patient to a UAP. What should the nurse ensure before delegating this task?

The patient is not at risk for falls
B. The patient has been educated about ambulation
C. The UAP has received training on proper body mechanics
D. The UAP has been assessed for the ability to use a walker

 

When should the nurse delegate a task to a UAP?

When the task requires critical thinking and nursing judgment
B. When the task is outside of the UAP’s scope of practice
C. When the task is routine and does not require assessment or nursing judgment
D. When the task involves teaching or patient education

 

Which action should the nurse take first when caring for a patient with severe burns?

Administer analgesics
B. Apply sterile dressing to the wounds
C. Assess the patient’s airway and breathing
D. Initiate an intravenous line

 

Which patient should the nurse assess first?

A 56-year-old patient with type 2 diabetes who reports feeling fatigued
B. A 30-year-old patient with a sprained ankle who is in moderate pain
C. A 45-year-old patient with chest pain and dizziness
D. A 60-year-old patient with mild shortness of breath and a cough

 

Which of the following should be delegated to an experienced RN rather than an LPN?

Administering oral medications
B. Assessing a newly admitted patient’s condition
C. Performing a sterile dressing change
D. Providing discharge teaching for a stable patient

 

Which of the following tasks can the nurse delegate to an LPN?

Assessing a patient’s nutritional needs
B. Administering medications, including IV push
C. Evaluating a patient’s response to a new treatment
D. Performing a routine dressing change

 

A nurse is prioritizing care for several patients in a medical unit. Which patient should the nurse assess first?

A patient with a fever and chills
B. A patient with chronic hypertension and headache
C. A patient with a new onset of confusion and restlessness
D. A patient recovering from surgery with stable vital signs

 

What action should the nurse take when a UAP is struggling to perform a delegated task properly?

Remind the UAP to complete the task independently
B. Reassign the task to another team member
C. Provide additional instructions and support to ensure the task is completed correctly
D. Document the UAP’s poor performance in the patient’s chart

 

Which task is most appropriate to delegate to a UAP in a busy hospital setting?

Administering a blood transfusion
B. Assessing a patient’s pain level
C. Assisting a patient to the bathroom
D. Developing a care plan for a new admission

 

Which of the following statements is true about the delegation of tasks to UAPs?

UAPs can independently assess patients’ needs
B. UAPs can provide direct patient education
C. The nurse remains responsible for the patient’s overall care
D. UAPs can administer intravenous medications

 

What is the first priority for a nurse caring for a patient who is experiencing a seizure?

Administer anticonvulsant medications
B. Ensure the patient’s safety and protect their airway
C. Observe and document the characteristics of the seizure
D. Call for assistance from the healthcare provider

 

Which task should be delegated to an experienced LPN in the care of a patient recovering from abdominal surgery?

Assessing the patient’s level of pain
B. Monitoring the patient’s urinary output
C. Teaching the patient how to care for the incision
D. Developing a discharge plan for the patient

 

Which patient should the nurse prioritize for immediate assessment?

A 60-year-old patient with a history of COPD and increased shortness of breath
B. A 70-year-old patient with a stable blood pressure and fatigue
C. A 50-year-old patient with intermittent dizziness and recent weight loss
D. A 35-year-old patient with a fractured ankle and mild pain

 

Which of the following tasks can be delegated to a UAP?

Administering a subcutaneous injection
B. Taking vital signs for a stable patient
C. Assisting with a complex wound dressing change
D. Educating the patient about medication side effects

 

Which of the following is the highest priority when a nurse is triaging patients in the emergency department?

A 70-year-old patient with a sprained wrist
B. A 45-year-old patient with a severe allergic reaction
C. A 30-year-old patient with a headache and fever
D. A 60-year-old patient with a history of back pain

 

Which action should the nurse take when delegating the task of feeding a patient with dysphagia to a UAP?

Instruct the UAP to feed the patient quickly to minimize the time spent on the task
B. Ensure the UAP has been trained in proper feeding techniques for patients with dysphagia
C. Allow the UAP to perform the task independently without oversight
D. Have the UAP provide the patient with thickened liquids only

 

The nurse is assigning tasks to the nursing team. Which of the following tasks should be assigned to an experienced LPN?

Assessing a patient’s response to a blood transfusion
B. Administering pain medication via IV push
C. Performing a sterile dressing change
D. Educating a patient on post-operative care

 

A nurse is preparing to delegate a task to a UAP. Which action is most appropriate before delegating?

Determine the complexity of the task and whether it is within the UAP’s scope of practice
B. Assign the task without providing any instructions to save time
C. Assume that the UAP knows the task and can perform it independently
D. Provide the UAP with the most difficult tasks to help them improve their skills

 

Which of the following patients should the nurse assess first when receiving shift report?

A 22-year-old patient with a headache who is being treated for a concussion
B. A 56-year-old patient with well-controlled hypertension and stable vitals
C. A 38-year-old patient post-operation who is complaining of moderate pain
D. A 65-year-old patient with sudden confusion and slurred speech

 

What is the most appropriate action for a nurse to take when delegating a non-critical task to a UAP?

Monitor the UAP’s performance of the task throughout the entire process
B. Provide clear instructions and expectations, then verify completion of the task
C. Assume that the UAP is aware of the task and can complete it independently
D. Assign a more critical task to the UAP to improve their skills

 

Which of the following should be the nurse’s first action when delegating tasks for a post-operative patient with unstable vital signs?

Delegate tasks that do not require assessment or judgment to a UAP
B. Assign the task of vital signs monitoring to an LPN and observe the patient closely
C. Delegate only non-urgent tasks to the UAP to allow time for observation
D. Ensure that the UAP is aware of the patient’s condition but assign routine tasks

 

Which of the following tasks should the nurse delegate to an LPN for a post-surgical patient who is stable?

Administering IV pain medication
B. Assessing the patient’s surgical site for signs of infection
C. Reinforcing the patient’s discharge teaching
D. Monitoring and recording the patient’s intake and output

 

Which task is appropriate to delegate to a UAP for a patient on bed rest?

Providing the patient with patient education on deep vein thrombosis prevention
B. Turning and repositioning the patient every two hours
C. Administering an anticoagulant injection
D. Assessing the patient’s skin for signs of pressure ulcers

 

Which action should the nurse prioritize when caring for a patient in the immediate post-operative period?

Ensuring that the patient is comfortable and pain is managed
B. Monitoring the surgical site for signs of infection
C. Assessing the patient’s airway and breathing status
D. Preparing discharge instructions for the patient

 

Which of the following patients should the nurse prioritize in an emergency room setting?

A patient with a sprained ankle who is in mild pain
B. A patient with a high fever and flu-like symptoms
C. A patient with a heart rate of 40 beats per minute and dizziness
D. A patient with a routine follow-up for a chronic illness

 

A nurse is delegating tasks to a UAP. Which of the following tasks is appropriate for delegation?

Checking the patient’s medication history
B. Assisting the patient with oral care
C. Teaching the patient how to use a walker
D. Assessing the patient’s pain level

 

Which of the following tasks can be delegated to a UAP for a patient who is receiving end-of-life care?

Providing emotional support to the family
B. Assisting the patient with comfort measures, such as repositioning
C. Explaining the patient’s prognosis to the family
D. Monitoring the patient’s medication regimen

 

The nurse is assigning a task to an LPN. Which of the following is appropriate for delegation?

Initiating a blood transfusion for a patient with anemia
B. Assessing a patient’s mental status after a head injury
C. Administering oral medications to a stable patient
D. Teaching a newly diagnosed diabetic patient about insulin administration

 

A patient has been admitted with chest pain. Which action should the nurse prioritize?

Assessing the patient’s oxygen saturation level
B. Administering the prescribed pain medication
C. Performing a full physical assessment
D. Obtaining a 12-lead ECG

 

Which of the following is an appropriate delegation to a UAP for a patient recovering from surgery?

Evaluating the surgical site for signs of infection
B. Assisting the patient to the bathroom
C. Administering post-operative medications
D. Monitoring the patient’s cardiac rhythm

 

Which task should the nurse assign to an experienced LPN?

Performing a head-to-toe assessment on a newly admitted patient
B. Monitoring the vitals of a post-operative patient and reporting abnormalities
C. Educating a diabetic patient on blood glucose management
D. Administering IV fluids to a patient with dehydration

 

Which of the following is the nurse’s highest priority when providing care to a patient with a head injury?

Monitoring the patient’s blood pressure
B. Ensuring the patient remains on bed rest
C. Assessing the patient’s neurological status frequently
D. Administering pain medications as ordered

 

When delegating the task of taking vital signs for a stable patient to a UAP, which of the following is important?

Instruct the UAP to also assess the patient’s mental status
B. Ensure that the UAP understands when to report abnormal vital signs
C. Ask the UAP to interpret the vital signs and provide a diagnosis
D. Refrain from providing instructions and assume the UAP knows what to do

 

A nurse receives a change of shift report. Which patient should be assessed first?

A 60-year-old with a stable blood pressure post-surgery
B. A 50-year-old with a history of diabetes and high blood pressure
C. A 30-year-old with complaints of abdominal pain and vomiting
D. A 75-year-old with confusion and a recent fall

 

Which of the following tasks can the nurse delegate to a UAP for a patient in a long-term care facility?

Administering an oral medication to a stable patient
B. Changing the dressing on a post-operative wound
C. Taking vital signs for a stable patient
D. Educating a family member about wound care

 

Which of the following is the most important action the nurse should take when caring for a patient with acute shortness of breath?

Ask the patient to rest and remain calm
B. Administer oxygen as prescribed
C. Evaluate the patient’s pain level
D. Have the patient lie flat to facilitate breathing

 

Which of the following tasks should the nurse delegate to an LPN for a patient who is post-operative and stable?

Teaching the patient about pain management options
B. Assessing the patient’s surgical site for signs of infection
C. Administering prescribed antibiotics
D. Performing a complete head-to-toe assessment

 

Which of the following is the priority action when the nurse finds that a patient’s IV infusion has infiltrated?

Apply a warm compress to the site
B. Discontinue the IV infusion and remove the catheter
C. Notify the healthcare provider immediately
D. Increase the IV infusion rate to flush the medication through

 

Which of the following is an appropriate task to delegate to a UAP in a busy emergency room setting?

Administering a tetanus shot to a patient with a deep laceration
B. Assisting a patient with hygiene after an accident
C. Assessing the pain level of a patient with a broken bone
D. Explaining discharge instructions to a patient with a sprained ankle

 

A nurse is delegating the task of collecting a urine specimen to a UAP. What should the nurse ensure before delegation?

Confirm that the UAP is familiar with the procedure for collecting a sterile specimen
B. Instruct the UAP to assist the patient with personal hygiene before collecting the specimen
C. Provide a complete list of instructions on how to collect the specimen without additional clarification
D. Ensure that the UAP understands how to analyze the specimen for abnormalities

 

Which of the following patients should be assessed first by the nurse in a triage situation?

A 25-year-old with a headache and fever
B. A 40-year-old with severe chest pain and shortness of breath
C. A 65-year-old with a leg wound and no signs of infection
D. A 30-year-old with a mild sprain to the ankle

 

When assigning care to a UAP, which of the following should the nurse consider?

The UAP’s comfort level with the task
B. The UAP’s knowledge and experience in performing the task
C. The UAP’s relationship with the patient
D. The UAP’s ability to work independently without supervision

 

The nurse is caring for a postoperative patient who is complaining of severe pain. Which action should the nurse prioritize?

Administering prescribed pain medication
B. Assessing the surgical site for complications
C. Offering comfort measures such as positioning
D. Educating the patient about post-operative care

 

A nurse receives a patient assignment that includes a patient with a new tracheostomy. Which action is the nurse’s highest priority?

Teaching the family how to care for the tracheostomy
B. Ensuring the tracheostomy tube is patent
C. Administering pain medication
D. Performing a full respiratory assessment

 

Which of the following tasks is appropriate for delegation to a UAP?

Administering IV medications to a patient in a critical condition
B. Assisting a patient with transferring from bed to chair
C. Evaluating the effectiveness of a pain management regimen
D. Teaching a patient how to perform self-care activities at home

 

A nurse is assigned to care for four patients. Which patient should be assessed first?

A patient with a history of hypertension who is stable
B. A patient who is post-operative and has a fever of 101°F
C. A patient who is 24 hours post-CVA and has slurred speech
D. A patient with a broken arm who is waiting for discharge

 

A nurse is delegating a task to an LPN. Which of the following tasks can be delegated?

Administering an IV push medication
B. Teaching a diabetic patient about insulin injection
C. Collecting a sterile urine specimen
D. Performing an initial assessment of a newly admitted patient

 

Which of the following tasks should the nurse assign to a UAP for a patient who is stable and has no acute medical needs?

Observing the patient’s response to pain medication
B. Assisting the patient with a bath and feeding
C. Administering IV fluids
D. Assessing the patient’s skin for breakdown

 

A nurse is caring for a patient who is receiving chemotherapy. Which of the following symptoms requires the nurse’s immediate attention?

Nausea and vomiting
B. Mild fatigue
C. Elevated temperature of 101.2°F
D. Mild hair thinning

 

The nurse is caring for a patient with a urinary tract infection (UTI). Which intervention should the nurse prioritize?

Administering prescribed antibiotics
B. Encouraging the patient to increase fluid intake
C. Obtaining a urine sample for culture and sensitivity
D. Providing comfort measures to relieve pain

 

A nurse is assigning tasks to a UAP. Which of the following tasks can the nurse safely delegate?

Giving a medication to a patient
B. Taking vital signs for a post-operative patient
C. Teaching a family member about wound care
D. Assessing the respiratory status of a patient with pneumonia

 

The nurse is caring for a patient with a history of stroke. Which of the following should be the nurse’s priority in this case?

Encouraging fluid intake to prevent dehydration
B. Educating the patient on post-stroke care
C. Assessing for signs of another stroke or complications
D. Reassessing the patient’s medication regimen

 

Which of the following tasks can be delegated to a UAP for a patient in a long-term care facility?

Monitoring oxygen saturation levels for a stable patient
B. Assisting the patient with ambulation
C. Administering a dose of oral medication
D. Performing a neurological assessment

 

Which of the following actions is most appropriate for the nurse to delegate to an experienced LPN?

Performing an initial assessment of a new admission
B. Assessing a patient’s level of consciousness after a fall
C. Administering oral medications and IV fluids as prescribed
D. Teaching a patient how to care for a surgical wound at home

 

Which of the following patients requires immediate attention from the nurse?

A 72-year-old patient with pneumonia who has increased dyspnea
B. A 50-year-old patient with diabetes who needs a follow-up on insulin administration
C. A 30-year-old patient with a mild sprain who is waiting for discharge
D. A 60-year-old patient with hypertension who has stable vital signs

 

A nurse is caring for a patient who is post-operative and has a PCA pump for pain management. The nurse should assess which of the following first?

The patient’s vital signs and respiratory rate
B. The patient’s pain level and effectiveness of the PCA pump
C. The patient’s level of consciousness and orientation
D. The surgical site for signs of infection

 

When delegating the task of turning and repositioning a bedridden patient to a UAP, the nurse should ensure that the UAP understands:

How to recognize and report signs of pressure ulcers
B. The steps for performing a head-to-toe assessment
C. The need for a comprehensive pain assessment
D. The steps for monitoring blood glucose levels

 

The nurse is caring for a patient who has just received an epidural for pain relief post-operatively. What is the priority assessment after the procedure?

Assessing the patient’s pain level
B. Monitoring for signs of infection at the insertion site
C. Assessing the patient’s respiratory rate and oxygen saturation
D. Checking the patient’s level of consciousness

 

A nurse is caring for a patient with a recent diagnosis of diabetic ketoacidosis (DKA). Which of the following tasks should the nurse prioritize?

Administering insulin according to the prescribed regimen
B. Monitoring blood glucose levels
C. Assessing for signs of electrolyte imbalances
D. Providing patient education on diabetes management

 

A nurse is assigned to care for a postoperative patient with a chest tube. What should be the nurse’s first priority?

Assessing the color and consistency of the drainage
B. Ensuring that the chest tube is properly secured and functioning
C. Teaching the patient about chest tube care
D. Administering pain medication

 

A nurse is preparing to discharge a patient who underwent a laparoscopic cholecystectomy. Which teaching topic should the nurse prioritize?

Signs and symptoms of infection at the incision site
B. Dietary modifications for the next six months
C. Exercises to prevent deep vein thrombosis (DVT)
D. Importance of regular follow-up appointments

 

Which of the following interventions should the nurse delegate to a UAP for a stable postoperative patient?

Teaching the patient how to use an incentive spirometer
B. Taking the patient’s vital signs and monitoring for complications
C. Administering oral medication
D. Performing a head-to-toe assessment

 

The nurse is caring for a patient who has a nasogastric (NG) tube. Which action should the nurse prioritize?

Ensuring that the NG tube is patent and functioning properly
B. Administering enteral nutrition through the NG tube
C. Monitoring the patient’s fluid intake and output
D. Checking the position of the NG tube after each use

 

The nurse is caring for a patient with end-stage heart failure who is on comfort care. Which of the following interventions is the priority?

Administering diuretics to relieve fluid retention
B. Providing a calm, supportive environment
C. Monitoring vital signs every 4 hours
D. Educating the family about the patient’s prognosis

 

A nurse is delegating the task of feeding a patient with dysphagia to a UAP. Which of the following should the nurse emphasize to the UAP?

Ensuring the patient is sitting upright during meals
B. Checking the patient’s swallowing function before feeding
C. Monitoring the patient for signs of aspiration after the meal
D. Providing assistance with oral hygiene after the meal

 

The nurse is caring for a patient who is receiving chemotherapy. Which of the following symptoms requires the nurse’s immediate attention?

Nausea and vomiting
B. Fever of 100.6°F
C. Dry mouth and altered taste
D. Low white blood cell count on laboratory results

 

A nurse is prioritizing care for several patients. Which patient should the nurse assess first?

A postoperative patient who is stable with clear lung sounds
B. A patient with a history of asthma who is complaining of shortness of breath
C. A patient with diabetes who needs to be taught about insulin administration
D. A patient recovering from a stroke with no complaints of pain or discomfort

 

A nurse is caring for a patient in labor who is in the transition phase. Which action should the nurse prioritize?

Monitoring fetal heart rate for any signs of distress
B. Encouraging the patient to take deep breaths between contractions
C. Administering pain medication as requested by the patient
D. Assessing the patient’s emotional state and providing reassurance

 

A nurse is delegating a task to a UAP. Which task is appropriate for the nurse to delegate?

Administering IV pain medication
B. Teaching a patient how to administer insulin
C. Monitoring the blood pressure of a stable patient
D. Performing a comprehensive physical assessment

 

A nurse is caring for a patient with chronic kidney disease. Which of the following actions is the priority in preventing complications?

Encouraging fluid intake to prevent dehydration
B. Monitoring laboratory results for electrolyte imbalances
C. Educating the patient on dietary restrictions
D. Administering prescribed medications on time

 

A nurse is caring for a postoperative patient who is at risk for deep vein thrombosis (DVT). Which intervention should the nurse prioritize?

Encouraging early ambulation
B. Administering prescribed anticoagulants
C. Applying compression stockings
D. Monitoring for signs of respiratory distress

 

Which of the following tasks should the nurse delegate to a UAP for a patient receiving IV therapy?

Monitoring the IV site for signs of infiltration
B. Assessing the patient’s response to pain medication
C. Administering the IV medication
D. Reassessing the patient’s vital signs after IV administration

 

The nurse is caring for a patient post-surgery who is complaining of sudden chest pain and shortness of breath. Which action should the nurse take first?

Administer prescribed pain medication
B. Take the patient’s vital signs
C. Notify the physician immediately
D. Apply oxygen to the patient

 

A nurse is preparing to discharge a patient with a new colostomy. Which action should be delegated to the UAP?

Teaching the patient how to care for the colostomy
B. Ensuring that the patient has adequate stoma supplies
C. Assisting the patient with dressing changes
D. Providing emotional support to the patient

 

A nurse is caring for a patient with severe burns. Which of the following actions should the nurse prioritize?

Administering pain medications
B. Providing wound care
C. Monitoring for signs of infection
D. Assessing the patient’s fluid status

 

The nurse is caring for a patient with a history of heart failure. Which of the following tasks should be delegated to the UAP?

Administering prescribed diuretics
B. Taking the patient’s vital signs
C. Assessing the patient for signs of heart failure exacerbation
D. Teaching the patient about dietary sodium restrictions

 

A nurse is caring for a patient in the emergency department with suspected meningitis. Which action should the nurse prioritize?

Administering prescribed antibiotics
B. Placing the patient in isolation precautions
C. Providing comfort measures for the patient
D. Checking the patient’s blood pressure

 

The nurse is caring for a patient with a newly diagnosed stroke. Which task is the most appropriate for delegation to a UAP?

Assessing the patient’s neurological status
B. Assisting the patient with activities of daily living (ADLs)
C. Administering clot-busting medication
D. Providing education about stroke prevention

 

A nurse is assessing a patient who has been receiving opioid pain medication. The patient is drowsy but arousable. What is the priority action for the nurse?

Reassess the patient’s pain level
B. Encourage the patient to drink fluids
C. Monitor the patient’s respiratory rate
D. Administer an additional dose of pain medication

 

A nurse is caring for a patient with a fresh myocardial infarction. What is the priority action for the nurse in the first hour?

Administering nitroglycerin as prescribed
B. Placing the patient on a cardiac monitor
C. Monitoring the patient’s blood pressure
D. Obtaining a baseline electrocardiogram (ECG)

 

A nurse is caring for a patient after a lumbar puncture. Which of the following is the priority action for the nurse?

Monitoring the patient for signs of infection
B. Assisting the patient to a sitting position to encourage spinal fluid drainage
C. Ensuring the patient stays in a supine position for several hours
D. Teaching the patient about post-procedure care

 

A nurse is caring for a patient with a newly inserted central venous catheter (CVC). Which action should the nurse prioritize?

Confirming the placement of the catheter with a chest X-ray
B. Administering prescribed medications through the catheter
C. Flushing the catheter with saline after each use
D. Teaching the patient about CVC care at discharge

 

A nurse is caring for a patient with a history of hypertension who has just been prescribed a new antihypertensive medication. What is the nurse’s priority action?

Assessing the patient’s blood pressure after administration
B. Instructing the patient on potential side effects of the medication
C. Taking the patient’s blood pressure before administering the medication
D. Reviewing the patient’s diet for sodium intake

 

The nurse is caring for a patient who is recovering from surgery and has a nasogastric (NG) tube in place. Which of the following actions should the nurse delegate to the UAP?

Checking the placement of the NG tube
B. Irrigating the NG tube to ensure patency
C. Providing patient education about the NG tube
D. Monitoring the patient for signs of nausea and vomiting

 

A nurse is providing care for a patient with a history of seizures. Which of the following actions should the nurse prioritize?

Administering seizure prophylaxis medications
B. Monitoring for signs of electrolyte imbalance
C. Ensuring the patient is in a safe environment to prevent injury
D. Providing patient education on seizure triggers

 

A nurse is caring for a patient who is at risk for developing a pressure ulcer. Which of the following interventions should the nurse prioritize?

Repositioning the patient every 2 hours
B. Administering a high-protein diet to promote healing
C. Monitoring the patient’s skin for signs of breakdown
D. Using a pressure-relieving mattress

 

A nurse is assessing a patient with a suspected pulmonary embolism. Which of the following signs or symptoms is the priority to report to the physician?

Tachypnea and shortness of breath
B. Chest pain that increases with inspiration
C. Decreased oxygen saturation levels
D. Anxiety and restlessness

 

The nurse is caring for a patient post-surgery who is exhibiting signs of dehydration. Which intervention should the nurse prioritize?

Administering prescribed IV fluids
B. Encouraging the patient to drink fluids orally
C. Monitoring the patient’s vital signs
D. Providing mouth care to the patient

 

The nurse is caring for a patient who is on a continuous heparin drip. Which of the following is the priority intervention?

Monitoring the patient’s platelet count
B. Assessing the patient’s INR levels
C. Monitoring for signs of bleeding
D. Ensuring that the patient remains on bed rest

 

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which of the following actions should the nurse prioritize?

Ensuring the patient’s oxygen levels are above 92%
B. Monitoring the patient for signs of oxygen toxicity
C. Administering bronchodilators as prescribed
D. Assessing the patient’s respiratory rate and effort

 

The nurse is caring for a patient who is at risk for aspiration pneumonia. Which action is the nurse’s priority?

Administering prescribed antibiotics
B. Ensuring that the patient is upright while eating
C. Encouraging the patient to cough and deep breathe
D. Monitoring the patient’s oxygen saturation levels

 

The nurse is caring for a patient who is about to undergo surgery and is anxious about the procedure. Which action should the nurse prioritize?

Offering the patient information about the procedure
B. Administering prescribed anti-anxiety medication
C. Providing comfort measures such as a warm blanket
D. Reassuring the patient that everything will be fine

 

A nurse is assessing a post-operative patient who has a urinary catheter in place. Which assessment finding requires immediate intervention?

The patient reports pain at the insertion site
B. The urine output is slightly cloudy
C. The urine output is below the expected amount
D. The urine is bright yellow in color

 

A nurse is delegating a task to a UAP. The UAP is unsure of how to complete the task. What should the nurse do?

Assign the task to another UAP who is more experienced
B. Complete the task themselves without involving the UAP
C. Provide guidance and ensure the UAP understands how to perform the task
D. Tell the UAP to ask the supervisor for clarification

 

The nurse is caring for a patient with a history of deep vein thrombosis (DVT) who is receiving anticoagulant therapy. Which of the following findings should be immediately reported to the physician?

Increased respiratory rate
B. Bleeding from the gums
C. Low-grade fever
D. Redness at the injection site

 

A nurse is caring for a patient with a nasogastric tube (NGT). Which action can the nurse delegate to the UAP?

Checking the placement of the NGT
B. Providing patient education about the NGT
C. Irrigating the NGT to ensure it is patent
D. Assessing the patient’s tolerance to the NGT

 

A nurse is caring for a patient who is receiving intravenous (IV) fluids at a rate of 125 mL per hour. The nurse notices that the IV is not infusing properly. Which of the following is the priority action?

Repositioning the IV site
B. Flushing the IV line with saline
C. Notifying the physician about the issue
D. Assessing the IV insertion site for signs of infiltration

 

A nurse is caring for a patient who is receiving chemotherapy. Which of the following interventions should be prioritized to manage the patient’s risk of infection?

Administering prescribed antibiotics
B. Encouraging adequate fluid intake
C. Monitoring for signs of infection such as fever
D. Providing a low-bacteria diet

 

The nurse is caring for a patient with a history of hypertension. The patient reports feeling dizzy upon standing. What is the nurse’s priority action?

Asking the patient to sit down and rest
B. Administering antihypertensive medication
C. Checking the patient’s blood pressure in both the supine and standing positions
D. Reassuring the patient that dizziness is common with hypertension

 

A nurse is caring for a patient who is receiving a blood transfusion. Which action should the nurse prioritize during the first 15 minutes of the transfusion?

Monitoring the patient for signs of a transfusion reaction
B. Increasing the transfusion rate if the patient is stable
C. Reassessing the patient’s vital signs
D. Documenting the start time of the transfusion

 

The nurse is caring for a patient with a history of asthma who is experiencing wheezing and shortness of breath. Which intervention should the nurse prioritize?

Administering prescribed bronchodilators
B. Taking the patient’s vital signs
C. Providing a calm and reassuring environment
D. Assessing the patient’s oxygen saturation levels

 

A nurse is caring for a patient post-surgery who is experiencing nausea and vomiting. Which intervention should the nurse prioritize?

Administering prescribed antiemetic medication
B. Monitoring the patient’s hydration status
C. Encouraging the patient to take sips of water
D. Reassessing the patient’s pain level

 

The nurse is caring for a patient with a head injury. The patient suddenly becomes restless and confused. What is the nurse’s priority action?

Administering prescribed sedatives
B. Reassessing the patient’s neurological status
C. Notifying the healthcare provider
D. Ensuring that the patient is in a safe environment

 

A nurse is caring for a patient who is scheduled for an MRI. The patient is claustrophobic and is expressing anxiety. What should the nurse do first?

Explain the procedure and reassure the patient
B. Administer anti-anxiety medication as prescribed
C. Offer a stress-relief technique, such as deep breathing
D. Notify the physician of the patient’s anxiety

 

A nurse is delegating a task to a UAP. Which task is the most appropriate to delegate?

Administering medications to a stable patient
B. Performing a full physical assessment on a new patient
C. Assisting a patient with bathing and dressing
D. Teaching a patient about a new diagnosis

 

The nurse is caring for a patient with chronic pain who has not had adequate pain relief. Which intervention should the nurse prioritize?

Administering prescribed pain medication
B. Assessing the effectiveness of non-pharmacological pain management strategies
C. Reassessing the patient’s pain level
D. Encouraging the patient to rest

 

A nurse is caring for a postoperative patient with a Jackson-Pratt drain. Which action should the nurse prioritize?

Emptying the drain and documenting the output
B. Assessing the wound for signs of infection
C. Repositioning the patient for comfort
D. Teaching the patient how to care for the drain

 

A nurse is caring for a patient who is about to be discharged with a prescription for warfarin. What is the priority teaching point the nurse should address?

The need to avoid foods high in vitamin K
B. The potential for bruising or bleeding
C. The importance of regular blood tests to monitor INR levels
D. The requirement to maintain a consistent exercise regimen

 

A nurse is caring for a patient with a history of diabetes who has a wound that is not healing. Which action should the nurse prioritize?

Reassessing the patient’s blood glucose levels
B. Applying an antibiotic ointment to the wound
C. Teaching the patient about proper wound care
D. Administering prescribed pain medications

 

A nurse is caring for a patient with a chest tube who has developed an air leak. Which action should the nurse take first?

Assess the patient’s respiratory status
B. Check the chest tube insertion site for drainage
C. Verify that the chest tube is properly connected
D. Notify the physician about the air leak

 

A nurse is caring for a patient with heart failure. The patient is experiencing shortness of breath, jugular venous distention, and swelling in the legs. What is the nurse’s priority intervention?

Administering a diuretic
B. Restricting the patient’s fluid intake
C. Administering oxygen therapy
D. Elevating the patient’s legs

 

A nurse is caring for a patient who is receiving chemotherapy and has developed a fever. Which action should the nurse prioritize?

Administering prescribed antibiotics
B. Taking a blood culture to identify the source of infection
C. Monitoring the patient’s temperature every hour
D. Notifying the healthcare provider of the fever

 

A nurse is caring for a patient with severe anxiety. The patient is hyperventilating and feels lightheaded. What is the nurse’s priority action?

Administering an anti-anxiety medication
B. Teaching the patient deep breathing techniques
C. Providing reassurance and comfort measures
D. Encouraging the patient to lie down

 

A nurse is assessing a patient with acute pancreatitis. The patient’s vital signs are stable, but they are complaining of severe abdominal pain. What should the nurse prioritize?

Administering pain medication as prescribed
B. Monitoring the patient’s blood pressure and heart rate
C. Encouraging the patient to take shallow breaths
D. Assessing the patient for signs of infection

 

A nurse is caring for a patient who is receiving an intravenous infusion of antibiotics. The patient begins to develop signs of an allergic reaction, including hives and difficulty breathing. What is the nurse’s priority action?

Stop the infusion immediately
B. Administer an antihistamine as prescribed
C. Notify the healthcare provider
D. Take the patient’s vital signs

 

The nurse is assessing a patient who has just received a blood transfusion. The nurse notices that the patient is experiencing chills and a fever. What is the priority action?

Continue the transfusion at the current rate
B. Stop the transfusion immediately and notify the physician
C. Administer antipyretic medication as prescribed
D. Take the patient’s vital signs and monitor for further changes

 

A nurse is caring for a patient who is post-surgery and reports severe nausea. What should the nurse do first?

Administer antiemetic medication as prescribed
B. Encourage the patient to drink fluids slowly
C. Assess the patient for signs of dehydration
D. Reassure the patient that nausea is normal post-surgery

 

The nurse is caring for a patient who has a central venous catheter (CVC). The nurse notices that the CVC is disconnected from the tubing. What is the nurse’s priority action?

Notify the healthcare provider immediately
B. Clamp the catheter and assess for signs of bleeding
C. Administer oxygen to the patient
D. Cover the catheter site with a sterile dressing

 

The nurse is preparing to delegate a task to a UAP. Which of the following tasks is most appropriate to delegate to a UAP?

Assessing a patient’s heart sounds
B. Teaching a patient about wound care
C. Assisting a patient with ambulation
D. Administering a prescribed intravenous medication

 

The nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD) who has developed dyspnea. What is the nurse’s priority intervention?

Administering a bronchodilator as prescribed
B. Encouraging the patient to use pursed-lip breathing
C. Elevating the head of the bed
D. Assessing the patient’s respiratory rate and oxygen saturation

 

A nurse is caring for a postoperative patient who is experiencing urinary retention. What is the nurse’s first priority action?

Inserting a urinary catheter
B. Encouraging the patient to drink fluids
C. Assessing the bladder for distention
D. Reassessing the patient’s pain level

 

A nurse is caring for a patient with a history of heart failure who is experiencing shortness of breath and fatigue. The patient’s lungs have crackles upon auscultation. What is the nurse’s priority action?

Administering oxygen as prescribed
B. Restricting the patient’s fluid intake
C. Encouraging the patient to cough and deep breathe
D. Administering a diuretic as prescribed

 

A nurse is assessing a patient after an epidural injection for pain relief. The patient reports difficulty breathing and a drop in blood pressure. What should the nurse do first?

Administer a prescribed vasopressor
B. Reassure the patient that these symptoms are normal
C. Assess the patient’s oxygen saturation and respiratory rate
D. Notify the healthcare provider immediately

 

A nurse is caring for a patient who has a prescription for a scheduled dose of insulin. The patient has not eaten and has a blood glucose level of 55 mg/dL. What should the nurse do?

Administer the insulin as prescribed
B. Hold the insulin dose and notify the healthcare provider
C. Encourage the patient to eat a meal and then administer the insulin
D. Administer the insulin with a small amount of food

 

A nurse is caring for a patient who is experiencing a seizure. What is the nurse’s first priority action?

Administering oxygen to the patient
B. Placing the patient on their side to prevent aspiration
C. Protecting the patient from injury
D. Notifying the healthcare provider

 

A nurse is caring for a postoperative patient who has developed a fever. The nurse notes that the patient’s surgical wound is red and warm to the touch. What is the nurse’s priority action?

Administering antipyretic medication
B. Applying a warm compress to the wound
C. Notifying the healthcare provider of the wound findings
D. Collecting a wound culture

 

The nurse is reviewing the medication list of a patient who is receiving warfarin. The nurse notes that the patient has recently started taking aspirin. What is the nurse’s priority action?

Notify the healthcare provider about the aspirin prescription
B. Educate the patient about the risk of bleeding associated with aspirin
C. Administer the warfarin dose as prescribed
D. Discontinue the aspirin prescription

 

The nurse is assessing a patient who is at risk for a deep vein thrombosis (DVT). Which intervention should the nurse prioritize?

Encouraging the patient to ambulate as tolerated
B. Administering anticoagulant therapy as prescribed
C. Elevating the patient’s legs to reduce swelling
D. Monitoring the patient’s vital signs for changes

 

A nurse is caring for a patient who is receiving chemotherapy and has developed neutropenia. What is the nurse’s priority action?

Administering growth factor medications as prescribed
B. Protecting the patient from infection by using strict hand hygiene
C. Monitoring the patient’s temperature every 4 hours
D. Encouraging the patient to maintain a high-calorie diet

 

A nurse is caring for a patient who is recovering from a stroke and has limited mobility on one side of the body. Which task is appropriate to delegate to a UAP?

Performing passive range-of-motion exercises
B. Evaluating the patient’s neurological status
C. Assisting the patient with ambulation
D. Providing a thorough assessment of the patient’s skin

 

A nurse is caring for a patient who is being treated with an opioid for pain relief. The patient begins to exhibit signs of respiratory depression. What is the nurse’s priority action?

Administering naloxone (Narcan) as prescribed
B. Monitoring the patient’s oxygen saturation levels
C. Reassessing the patient’s pain level
D. Notifying the healthcare provider immediately

 

A nurse is caring for a patient who is in labor and is experiencing strong contractions every 2 minutes. The cervix is dilated to 8 cm. What is the nurse’s priority action?

Preparing the patient for delivery
B. Administering pain relief medications
C. Monitoring the fetal heart rate for distress
D. Encouraging the patient to use breathing techniques

 

The nurse is caring for a patient who has been prescribed a continuous IV infusion of potassium chloride. The nurse notes that the patient’s urine output has decreased. What is the nurse’s priority action?

Continue the infusion and monitor for changes
B. Stop the infusion and notify the healthcare provider
C. Increase the rate of the IV infusion
D. Administer diuretics to increase urine output

 

A nurse is caring for a patient who has just undergone a lumbar puncture. What is the priority nursing action to prevent complications?

Encourage the patient to remain in a sitting position
B. Monitor for signs of cerebrospinal fluid leakage
C. Encourage the patient to ambulate after 4 hours
D. Keep the patient in a supine position for 6-8 hours

 

The nurse is caring for a postoperative patient who is experiencing nausea and vomiting after surgery. What is the priority action?

Administer an antiemetic as prescribed
B. Encourage the patient to drink clear fluids
C. Assess the patient’s abdominal status
D. Encourage deep breathing exercises

 

The nurse is preparing to delegate a task to a UAP. Which of the following tasks should be delegated?

Assessing the pain level of a postoperative patient
B. Administering IV fluids to a dehydrated patient
C. Measuring the vital signs of a stable patient
D. Reviewing a patient’s laboratory results

 

A nurse is caring for a patient who has a nasogastric tube (NGT) for feeding. The nurse notes that the patient is coughing and choking during the feeding. What is the nurse’s priority action?

Stop the feeding immediately and suction the airway
B. Notify the healthcare provider about the issue
C. Increase the flow rate of the feeding to prevent aspiration
D. Reposition the patient to a more upright position

 

A nurse is caring for a patient receiving total parenteral nutrition (TPN). The nurse notes that the patient’s blood sugar is 250 mg/dL. What is the priority nursing action?

Administer insulin as prescribed
B. Notify the healthcare provider immediately
C. Continue monitoring the blood sugar levels
D. Discontinue the TPN infusion

 

A nurse is caring for a patient who is receiving chemotherapy and is experiencing mucositis. What is the priority nursing intervention?

Encourage the patient to drink warm liquids
B. Offer soft, bland foods and encourage frequent oral care
C. Provide a saline mouth rinse to soothe the mucosa
D. Administer pain medication as prescribed

 

A nurse is caring for a postoperative patient who is at risk for deep vein thrombosis (DVT). What is the priority action to prevent this complication?

Administering prescribed anticoagulant therapy
B. Encouraging early ambulation and leg exercises
C. Applying compression stockings as prescribed
D. Monitoring for signs of redness and swelling in the legs

 

A nurse is caring for a patient with a history of asthma who is experiencing shortness of breath and wheezing. What is the nurse’s first priority?

Administering a bronchodilator as prescribed
B. Encouraging the patient to use a peak flow meter
C. Reassessing the patient’s vital signs and oxygen saturation
D. Notifying the healthcare provider immediately

 

A nurse is caring for a patient who is postoperative and has an indwelling urinary catheter. The nurse notes that the urine output has decreased significantly. What is the nurse’s priority action?

Increase the IV fluids to promote urine output
B. Assess the catheter for any signs of blockage
C. Notify the healthcare provider immediately
D. Encourage the patient to increase fluid intake

 

A nurse is caring for a patient with pneumonia who is receiving oxygen therapy. The nurse notices that the patient is becoming increasingly confused and restless. What is the nurse’s priority action?

Increase the oxygen flow rate
B. Reassess the patient’s vital signs and oxygen saturation
C. Administer a sedative as prescribed
D. Notify the healthcare provider immediately

 

The nurse is caring for a patient who has a prescription for an oral hypoglycemic agent. The patient reports feeling dizzy and weak. What is the nurse’s priority action?

Assess the patient’s blood glucose level
B. Offer the patient a snack with carbohydrates
C. Notify the healthcare provider immediately
D. Administer the oral hypoglycemic agent

 

A nurse is caring for a patient with a suspected myocardial infarction. What is the priority action?

Administer nitroglycerin as prescribed
B. Obtain an ECG to confirm the diagnosis
C. Administer oxygen therapy as prescribed
D. Reassure the patient and provide pain relief

 

A nurse is caring for a patient receiving IV fluids through a central venous catheter. The nurse notices that the catheter is not flushing easily. What is the nurse’s priority action?

Attempt to flush the catheter with more force
B. Assess the catheter for any kinks or occlusions
C. Notify the healthcare provider immediately
D. Discontinue the IV and start a new line

 

A nurse is caring for a patient with cirrhosis who develops ascites. What is the nurse’s priority intervention?

Administer diuretics as prescribed
B. Encourage the patient to restrict sodium intake
C. Monitor the patient’s respiratory status
D. Position the patient in a high-Fowler’s position

 

A nurse is caring for a patient who has been prescribed morphine for severe pain. The nurse notices the patient is becoming increasingly drowsy and difficult to arouse. What is the nurse’s priority action?

Notify the healthcare provider immediately
B. Administer naloxone as prescribed
C. Assess the patient’s respiratory rate and oxygen saturation
D. Increase the frequency of monitoring vital signs

 

A nurse is caring for a patient who has a history of hypertension and has just been started on a new antihypertensive medication. What is the nurse’s priority action?

Monitor the patient’s blood pressure regularly
B. Administer the medication with food to prevent nausea
C. Instruct the patient to avoid consuming grapefruit juice
D. Assess for signs of orthostatic hypotension

 

The nurse is caring for a patient with a chest tube for a pneumothorax. The nurse notes that the water-seal chamber of the chest tube system is fluctuating with the patient’s respirations. What is the nurse’s priority action?

Continue to monitor the fluctuation, as it is a normal finding
B. Notify the healthcare provider about the fluctuation
C. Assess the chest tube for patency
D. Clamp the chest tube to prevent further fluctuation

 

A nurse is caring for a patient who is being discharged with a prescription for warfarin. What is the nurse’s priority teaching point for this patient?

Take the medication at the same time each day
B. Avoid eating foods rich in vitamin K
C. Limit physical activity to reduce the risk of bleeding
D. Monitor for signs of dehydration, such as dizziness

 

A nurse is caring for a patient receiving a blood transfusion. The nurse notices the patient is becoming increasingly anxious, experiencing chills, and has a fever. What is the nurse’s priority action?

Slow the rate of the blood transfusion and notify the healthcare provider
B. Stop the blood transfusion immediately and assess for signs of a reaction
C. Continue the transfusion and administer antipyretics
D. Monitor the patient’s vital signs and continue the transfusion

 

The nurse is caring for a patient receiving heparin therapy. The nurse observes that the patient has bruising at the injection site. What is the nurse’s priority action?

Administer the next dose of heparin as scheduled
B. Assess the patient for any signs of bleeding in other areas
C. Notify the healthcare provider immediately
D. Document the findings in the patient’s chart

 

A nurse is caring for a patient who has been diagnosed with diabetic ketoacidosis (DKA). The patient is receiving IV insulin. What is the nurse’s priority action?

Administer potassium supplementation as prescribed
B. Monitor the patient’s blood glucose every hour
C. Maintain the patient’s IV fluids at a high rate
D. Prepare for possible intubation

 

A nurse is caring for a patient who has been diagnosed with a stroke. The patient is exhibiting signs of dysphagia. What is the nurse’s priority action?

Prepare the patient for a speech therapy evaluation
B. Provide the patient with thickened liquids and soft foods
C. Instruct the patient to perform swallowing exercises
D. Monitor the patient’s swallowing ability during meals

 

A nurse is caring for a patient who has recently been prescribed a new antihypertensive medication. The patient’s blood pressure is 90/58 mmHg. What is the nurse’s priority action?

Administer the medication with food to prevent nausea
B. Reassess the patient’s blood pressure after 30 minutes
C. Hold the medication and notify the healthcare provider
D. Encourage the patient to drink fluids to raise the blood pressure

 

A nurse is caring for a patient who is receiving a continuous IV infusion of furosemide. The nurse notices that the patient is developing signs of hypokalemia. What is the nurse’s priority action?

Administer potassium supplements as prescribed
B. Increase the rate of the IV infusion
C. Notify the healthcare provider about the potassium imbalance
D. Monitor the patient’s vital signs for signs of cardiac arrhythmias

 

The nurse is caring for a patient with a history of seizures. The nurse notes that the patient is exhibiting signs of agitation, confusion, and disorientation. What is the nurse’s priority action?

Reassure the patient and attempt to calm them down
B. Perform a full neurological assessment
C. Administer an anticonvulsant medication as prescribed
D. Check the patient’s blood glucose level

 

A nurse is caring for a patient who is receiving an IV infusion of a sedative medication. The patient becomes unresponsive, and the nurse is unable to detect a pulse. What is the nurse’s first priority action?

Initiate cardiopulmonary resuscitation (CPR)
B. Call for help and activate the emergency response system
C. Administer naloxone if an opioid is suspected
D. Check the patient’s airway for obstruction

 

A nurse is caring for a patient who is receiving a blood transfusion. The nurse notices the patient is experiencing back pain, chills, and a fever. What is the priority nursing action?

Stop the blood transfusion immediately
B. Administer acetaminophen for fever
C. Increase the rate of the blood transfusion
D. Assess the patient’s vital signs and document findings

 

True And False

 

1. A nurse should always delegate the responsibility of assessing a patient’s condition to a nursing assistant.

Answer:

2. The nurse should prioritize care based on the ABCs (Airway, Breathing, Circulation) of patient assessment.

Answer:

3. It is acceptable for a nurse to delegate medication administration to a nursing assistant if they are familiar with the medication.

Answer:

4. A nurse can delegate the task of changing a sterile dressing to a licensed practical nurse (LPN) in most cases.

Answer:

5. When prioritizing care, a nurse should consider the patient’s preferences before addressing life-threatening conditions.

Answer:

6. The nurse can delegate the task of monitoring a patient’s vital signs to a nursing assistant as long as they are stable.

Answer:

7. A nurse can delegate patient education to a nursing assistant as long as they are trained in the content.

Answer:

8. The nurse should always delegate non-invasive tasks to unlicensed personnel, such as a nursing assistant or medical technician.

Answer:

9. A nurse should prioritize care for patients who are at the highest risk for complications, even if they are not experiencing symptoms.

Answer:

10. A nurse can delegate the task of performing a urinary catheterization to a licensed practical nurse (LPN) in a stable patient.

Answer:

11. It is appropriate to delegate the task of performing a comprehensive physical assessment to a nursing assistant if the patient is stable.

Answer:

12. The nurse should delegate tasks based on the patient’s condition, the skill level of the delegatee, and the complexity of the task.

Answer:

13. It is always appropriate to delegate the responsibility of monitoring a patient’s pain level to a nursing assistant.

Answer:

14. In an emergency situation, the nurse should prioritize tasks based on urgency and the potential for harm to the patient.

Answer:

15. It is acceptable for a nurse to delegate the task of administering insulin injections to an unlicensed assistive personnel (UAP) if the patient is stable.

Answer:

16. The nurse should always delegate tasks to personnel who have the appropriate education, training, and experience for the task.

Answer:

17. A nurse can delegate routine tasks, such as bathing or feeding, to a nursing assistant for a patient who is recovering well from surgery.

Answer:

18. The nurse should prioritize the care of a postoperative patient who is experiencing severe pain over a patient with a mild fever but no other symptoms.

Answer:

19. A nurse should immediately delegate all tasks to the appropriate personnel without assessing the patient’s current condition.

Answer:

20. Delegation decisions should be guided by the principle that the nurse remains accountable for the outcome of the task, even when it has been delegated.

Answer:

 

Questions and Answers for Study Guide

 

Describe the key principles involved in nursing prioritization and explain how these principles guide the nurse in determining which patients need immediate attention.

Answer:

Nursing prioritization involves assessing patient needs based on urgency, severity, and the potential impact of untreated conditions. The primary principles include:

• ABC (Airway, Breathing, Circulation): This prioritization system ensures that life-threatening conditions are addressed first. For example, if a patient is having difficulty breathing or has compromised circulation, those issues take precedence over less critical concerns.
• Maslow’s Hierarchy of Needs: Nurses often prioritize tasks based on the basic human needs, starting from physiological needs (e.g., oxygen, food, and water) to psychological needs (e.g., safety and emotional well-being).
• The Nursing Process: Nurses use assessment, diagnosis, planning, implementation, and evaluation to structure care based on patient conditions. The process ensures that immediate, critical needs are addressed before moving on to other concerns.

By applying these principles, nurses ensure that life-threatening conditions are identified and treated promptly, thereby preventing complications and improving patient outcomes.

 

What are the key factors to consider when delegating tasks in nursing, and how do these factors impact the safety and effectiveness of patient care?

Answer:

When delegating tasks, nurses must consider several key factors:

• Patient Stability and Complexity: Tasks that require clinical judgment, such as assessing vital signs or making changes to treatment plans, should not be delegated to unlicensed personnel. However, routine tasks such as bathing or transporting stable patients can be delegated to nursing assistants.
• Competency of the Delegatee: The nurse must ensure the individual performing the task is competent to do so. If a task is outside the scope of practice for the delegatee, it should not be assigned to them. For example, administering medications or interpreting lab results requires a licensed nurse.
• Scope of Practice and Legal Considerations: The scope of practice for registered nurses (RNs), licensed practical nurses (LPNs), and nursing assistants varies. It is essential to know what each professional can and cannot do according to state laws and institutional policies.
• Supervision and Communication: Effective communication and clear instructions are necessary when delegating tasks. The nurse must ensure that the delegatee understands the task and knows when to seek help. Regular supervision ensures that tasks are completed correctly and safely.

Delegation impacts patient safety because the nurse maintains responsibility for the care given, even when tasks are delegated. When done appropriately, delegation allows for more efficient care, improves workload management, and helps meet patient needs effectively.

 

Explain the importance of delegation in nursing and how poor delegation can affect the quality of patient care.

Answer:

Delegation is crucial in nursing to ensure that tasks are distributed appropriately based on the level of complexity and expertise. Proper delegation helps ensure that nursing teams can manage workloads effectively and provide high-quality care to patients.

The importance of delegation in nursing includes:

• Efficient Use of Time and Resources: Delegation allows nurses to focus on tasks that require critical thinking and advanced clinical judgment, while routine or less complex tasks can be handled by nursing assistants or LPNs.
• Improved Patient Care: When nurses delegate appropriately, they can ensure that all patient needs are addressed, which leads to better care coordination and outcomes. Delegation also enables the timely completion of care tasks, reducing delays in treatment.
• Promoting Team Collaboration: Delegation fosters a collaborative work environment, where team members contribute according to their skill levels, improving overall team dynamics and efficiency.

However, poor delegation can have several negative effects:

• Increased Risk of Errors: When tasks are delegated to individuals who are not competent or do not fully understand the task, it can result in mistakes that compromise patient safety.
• Nurse Burnout: If nurses fail to delegate effectively, they may become overwhelmed by their workload, leading to fatigue, stress, and burnout. This reduces their ability to perform their duties efficiently.
• Compromised Patient Outcomes: If delegation is poorly executed, essential tasks may be overlooked, leading to complications and delayed interventions. For example, a nurse may fail to delegate the task of monitoring a patient’s vital signs to the appropriate personnel, which can result in missed critical changes in the patient’s condition.

In summary, delegation is a key element of nursing practice that, when done correctly, improves patient care and optimizes the efficiency of healthcare teams. Poor delegation, however, can lead to adverse outcomes for both patients and nursing staff.

 

Discuss the challenges nurses face in prioritizing patient care and how these challenges can be addressed to improve clinical outcomes.

Answer:

Nurses face a variety of challenges in prioritizing patient care, some of which stem from the complexity of patients’ conditions, time constraints, and the dynamic nature of the healthcare environment. Key challenges include:

• Multiple Competing Priorities: Nurses often have to care for multiple patients with varying degrees of acuity. Determining which patient needs immediate attention can be difficult when all patients seem urgent. For example, a patient with severe pain may require immediate intervention, while another patient may be at risk for respiratory failure.
• Time Constraints: In a busy healthcare setting, nurses frequently work under pressure, with limited time to assess, plan, and implement care. This time pressure can lead to the tendency to focus on immediate, visible concerns, while more subtle but equally critical issues may be neglected.
• Inadequate Staffing: A shortage of nurses or support staff can exacerbate the challenge of prioritization. Nurses may find themselves responsible for too many patients, leading to potential lapses in care.
• Clinical Judgment and Experience: Inexperienced nurses may struggle with making the right decisions regarding patient prioritization. This issue can be mitigated with mentorship and ongoing education in critical thinking and clinical reasoning.

To address these challenges and improve clinical outcomes, the following strategies can be implemented:

• Enhanced Communication: Clear communication among the healthcare team is vital. Regular handoffs and briefings ensure that all team members are aware of patient priorities and can contribute to decision-making.
• Time Management and Organizational Skills: Nurses can improve their ability to prioritize by developing strong time management skills. For example, creating lists or using tools such as the “ABCDE” method (Airway, Breathing, Circulation, Disability, Exposure) can help prioritize tasks.
• Ongoing Education and Mentorship: Offering continuous education and mentorship can help nurses improve their clinical judgment. Training in prioritization techniques and understanding the principles of the nursing process can help new nurses become more confident in their decision-making.

By addressing these challenges, nurses can make better prioritization decisions, reduce the risk of errors, and ultimately improve patient outcomes.

 

Describe the role of the nurse in ensuring effective delegation and explain how the nurse maintains accountability for tasks that have been delegated.

Answer:

The nurse plays a central role in ensuring effective delegation by following established principles and ensuring that tasks are assigned to appropriate personnel. The nurse’s responsibilities include:

• Assessing the Task: Before delegating any task, the nurse should assess its complexity and determine whether it is within the scope of practice for the delegatee. Tasks that require clinical judgment or the potential for complications should be performed by registered nurses, while routine, non-complex tasks may be delegated to nursing assistants or LPNs.
• Selecting the Right Person: The nurse must ensure that the person being delegated the task has the required skills, knowledge, and experience to perform the task safely and competently. This includes ensuring that the delegatee understands the task and its potential risks.
• Providing Clear Instructions: The nurse must give clear, concise, and complete instructions to the person taking on the delegated task. They must ensure that the delegatee understands the steps involved, when the task is due, and what to do if complications arise.
• Monitoring and Supervision: Even when tasks are delegated, the nurse is ultimately responsible for ensuring that they are completed correctly. This involves monitoring the delegatee’s performance, offering guidance when needed, and making sure that the task is completed according to established standards.
• Maintaining Accountability: Nurses remain accountable for the patient’s care, even when tasks are delegated. This means that the nurse must evaluate whether the delegation was appropriate and whether the task was carried out correctly. If errors occur, the nurse must take responsibility and address the issue promptly.

In summary, effective delegation involves the nurse’s ability to assess, select, communicate, and supervise. Accountability remains with the nurse, ensuring that patient care is safe, efficient, and of high quality.

 

Discuss how the nurse determines the priority of care for patients with different levels of acuity and explain the reasoning behind prioritization in nursing.

Answer:

In nursing, determining the priority of care is essential to ensure that patients receive the most appropriate and timely interventions based on their acuity level. Nurses use several frameworks and critical thinking processes to make these decisions:

• High Acuity: Patients in critical conditions such as those experiencing acute respiratory distress, shock, or chest pain are given top priority. The nurse’s priority is to stabilize these patients using the ABCs (Airway, Breathing, Circulation) as a guide. Immediate interventions, such as oxygen administration, resuscitation, or pain management, are necessary to prevent further deterioration.
• Moderate Acuity: Patients who are stable but require monitoring, such as those recovering from surgery or those with chronic conditions under control, are considered moderate acuity. Nurses prioritize assessments to ensure their condition doesn’t worsen, adjusting care as needed.
• Low Acuity: These patients are generally stable and have minimal immediate health concerns. The nurse can spend time educating the patient, ensuring comfort, and providing preventive care, but these patients can typically wait for care without compromising their outcomes.

Prioritization decisions are based on assessing each patient’s immediate and potential risks, ensuring that life-threatening situations are addressed first. The goal is to manage patients in a way that minimizes harm and maximizes recovery.

 

How does the nurse use critical thinking in delegation, and why is critical thinking essential for effective delegation in nursing?

Answer:

Critical thinking in nursing is the process of actively analyzing, evaluating, and applying information to make decisions in patient care. It is essential when delegating tasks to ensure that the nurse’s judgment is sound and that patient safety is maintained.

• Assessing the Task: Critical thinking enables nurses to determine the complexity and risk level of the task being considered for delegation. The nurse must evaluate whether the task requires clinical judgment or if it can be performed by another healthcare worker with appropriate training. For example, administering medications requires critical thinking, while assisting with ambulation may not.
• Understanding the Scope of Practice: A critical thinker must also consider the legal and ethical scope of practice for all team members. For instance, nurses must understand the roles of RNs, LPNs, and nursing assistants to avoid inappropriate delegation, which could compromise patient safety.
• Evaluating Potential Outcomes: By using critical thinking, nurses consider the potential consequences of delegation. Will the task, if not done correctly, harm the patient? Are there risks to the patient’s safety that must be addressed? Nurses think ahead to foresee complications and ensure the right person is given responsibility for the task.

Critical thinking enhances effective delegation by helping the nurse maintain accountability and ensure that tasks are appropriately assigned, reducing the chance of errors and optimizing patient care.

 

What strategies can nurses use to improve their delegation skills and ensure the delegation process is effective and safe for patients?

Answer:

Improving delegation skills is crucial for effective nursing practice and ensuring patient safety. Here are several strategies nurses can use:

• Know Your Team’s Skills: To delegate tasks effectively, a nurse must be familiar with the strengths and weaknesses of team members. Knowing who is competent in specific areas allows nurses to assign appropriate tasks to those who can perform them safely and efficiently.
• Clear Communication: One of the most important strategies for successful delegation is clear and concise communication. Nurses must provide detailed instructions and expectations for each task. The delegated person must understand the task and be aware of when to ask for help or clarification if necessary.
• Provide Proper Training and Supervision: Nurses should ensure that the individuals they delegate to are adequately trained for the task at hand. This includes training on specific procedures or patient care techniques. Ongoing supervision ensures tasks are completed according to standards, and corrective actions can be taken promptly if needed.
• Use Tools for Prioritization: Utilizing tools such as checklists or task management apps helps nurses prioritize delegated tasks and monitor their completion. These tools can help keep track of what has been delegated, preventing any task from being overlooked or forgotten.
• Empower Team Members: Nurses can improve delegation by fostering an environment of trust and collaboration. Empowering team members to make decisions when appropriate can enhance their confidence and skill level, making delegation more effective.

By applying these strategies, nurses can delegate tasks in a way that improves efficiency and patient outcomes while maintaining accountability and safety.

 

Explain the concept of “priority setting” in nursing and discuss how a nurse can effectively prioritize care in a busy healthcare environment.

Answer:

Priority setting in nursing refers to the process by which nurses determine which tasks, interventions, or patients need immediate attention and which can be addressed later. This concept is integral to delivering efficient and safe care, particularly in busy and resource-limited healthcare settings.

• Use of the ABCs Framework: Nurses often use the ABCs (Airway, Breathing, Circulation) as a guide to prioritize care. For example, if a patient is experiencing difficulty breathing, it takes precedence over other less urgent matters, such as dressing changes or routine medication administration.
• Triage System: In emergency settings, nurses use triage principles to categorize patients based on the severity of their conditions. This helps prioritize patients who are at the greatest risk and require immediate intervention.
• Clinical Judgement and Time Management: Nurses also rely on clinical judgment, which involves assessing a patient’s condition, using critical thinking to identify urgent issues, and making timely decisions. Effective time management is also crucial. The nurse must balance urgent care with routine tasks, ensuring no patient is neglected.
• Delegation of Non-Essential Tasks: Nurses in busy environments often delegate non-critical tasks, such as assisting with meals or turning patients, to other staff members to allow time for more pressing matters.

By combining prioritization frameworks with effective time management and delegation skills, nurses can ensure that they meet patients’ most critical needs in a timely manner, even in busy healthcare environments.

 

What role does delegation play in reducing nurse burnout, and how can poor delegation practices contribute to nurse stress and fatigue?

Answer:

Delegation plays a significant role in reducing nurse burnout by allowing nurses to manage their workloads more effectively. When nurses delegate appropriately, they can focus on tasks that require clinical expertise, while routine or less complex tasks are assigned to other team members. Here are key points explaining the role of delegation in reducing burnout:

• Workload Management: Effective delegation helps nurses manage their workload by ensuring that no single nurse is responsible for all tasks. By sharing responsibilities with others, nurses can avoid feeling overwhelmed and exhausted, which contributes to a more balanced workload.
• Preventing Overwork: Without proper delegation, nurses may end up performing tasks that could be handled by others, leading to overwork. This overburdened workload can lead to stress, emotional exhaustion, and physical fatigue—key factors contributing to burnout.
• Increased Job Satisfaction: When nurses delegate effectively, they are able to perform tasks that align with their professional skills and training, which enhances job satisfaction. A feeling of accomplishment can mitigate feelings of burnout.

However, poor delegation practices can lead to:

• Increased Stress: When tasks are not delegated properly, nurses can become overwhelmed by managing every aspect of patient care. This causes stress and reduces the quality of care provided to patients.
• Neglecting Patient Care: If nurses are unable to delegate appropriately, essential tasks may be missed or delayed, which increases the risk of patient complications. This not only affects patient outcomes but also heightens the nurse’s stress.
• Burnout: Continuous overwork, without delegation, leads to emotional and physical exhaustion. Nurses who do not delegate effectively are at higher risk of burnout, which affects their well-being, job performance, and retention in the profession.

In summary, delegation is a key strategy for reducing burnout by promoting effective workload management, job satisfaction, and preventing stress. Poor delegation, however, can lead to increased stress, neglect of patient care, and ultimately burnout.

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