BSN Prioritization, Delegation, and Assignment 2

Question 1

A nurse is caring for four patients. Which patient should the nurse assess FIRST using the ABCs framework?

Accepted Answer

A patient with oxygen saturation of 88% on room air

Answer

A patient with a blood glucose of 200 mg/dL

Answer

A patient requesting pain medication for a headache rated 5/10

Answer

A patient who needs discharge teaching before going home

Question 2

Which action by a nursing assistant (NA) during morning care requires the RN to intervene immediately?

Accepted Answer

The NA performs oral care on an unconscious patient with the head of bed flat

Answer

The NA assists the patient to the bathroom using a gait belt

Answer

The NA obtains a routine blood pressure on a stable patient

Answer

The NA records the patient's oral fluid intake on the I&O sheet

Question 3

A charge nurse is assigning patients. Which patient is MOST appropriate to assign to a newly licensed RN still on orientation?

Accepted Answer

A patient post-op day 2 following an appendectomy with stable vital signs

Answer

A patient with a new tracheostomy requiring suctioning every 2 hours

Answer

A patient in alcohol withdrawal showing early signs of delirium tremens

Answer

A patient receiving a continuous heparin drip for pulmonary embolism

Question 4

Under which circumstance is it appropriate to delegate a task to a licensed practical nurse (LPN)?

Accepted Answer

Administering a routine oral medication to a stable patient

Answer

Performing the initial nursing assessment on a newly admitted patient

Answer

Developing a patient's individualized care plan

Answer

Evaluating the patient's response to a new pain management protocol

Question 5

A nurse uses the SBAR communication tool when handing off a deteriorating patient. What does the 'R' stand for?

Accepted Answer

Recommendation

Answer

Report

Answer

Review

Answer

Response

Question 6

Which of the following tasks CANNOT be delegated to an unlicensed assistive personnel (UAP) by an RN?

Accepted Answer

Performing a focused respiratory assessment on a patient with new-onset shortness of breath

Answer

Measuring and recording urine output

Answer

Ambulating a stable postoperative patient in the hallway

Answer

Obtaining a routine set of vital signs on a stable patient

Question 7

A nurse is prioritizing care using Maslow's Hierarchy of Needs. Which patient need should be addressed first?

Accepted Answer

A patient with acute urinary retention causing significant pain and bladder distension

Answer

A patient who feels isolated and wants visitors

Answer

A patient who is anxious about an upcoming surgery scheduled for tomorrow

Answer

A patient who requests a specific type of pillow for comfort