BSN Prioritization, Delegation, and Assignment 3 — Questions and Answers
Question 1: A nurse receives a telephone order from a physician. Which is the BEST action to ensure accuracy?
- Write the order immediately and have the charge nurse cosign it
- Read back the complete order to the physician and document 'T.O. read back and verified' (Correct answer)
- Ask the physician to enter the order directly into the electronic health record
- Repeat the order back only if it involves a controlled substance
Correct answer: Read back the complete order to the physician and document 'T.O. read back and verified'
Reading back the entire order and documenting verification is the safest practice to prevent miscommunication errors with telephone orders.
Question 2: When delegating, the RN is responsible for which of the following?
- Performing the task alongside the delegate every time
- Supervising and evaluating the outcome of the delegated task (Correct answer)
- Accepting sole accountability only if the delegate makes an error
- Delegating based on the delegate's personal preference
Correct answer: Supervising and evaluating the outcome of the delegated task
The RN retains accountability for the outcome and must supervise and evaluate whether the delegated task was completed safely and correctly.
Question 3: A nurse has five tasks to complete in the next hour. Which should be done LAST?
- Administering a stat IV antibiotic for a patient with sepsis
- Changing the dressing on a surgical wound that is due now
- Providing discharge education to a patient leaving in 4 hours (Correct answer)
- Responding to a patient whose call light is on for uncontrolled chest pain
Correct answer: Providing discharge education to a patient leaving in 4 hours
Discharge education for a patient leaving in 4 hours is the lowest urgency task among life-threatening and time-sensitive priorities.
Question 4: Which principle of the Five Rights of Delegation addresses whether the environment is appropriate for the task to be safely performed?
- Right task
- Right person
- Right circumstance (Correct answer)
- Right supervision
Correct answer: Right circumstance
The Right Circumstance evaluates whether the setting, resources, and patient condition make it safe and appropriate to delegate the task.
Question 5: A nurse is caring for a patient on contact precautions. Which task is safe to delegate to a UAP?
- Assessing skin integrity during bath
- Assisting the patient with a bed bath using proper PPE (Correct answer)
- Deciding whether to continue the contact precautions
- Educating the patient about hand hygiene importance
Correct answer: Assisting the patient with a bed bath using proper PPE
Assisting with a bed bath is a routine personal care task within UAP scope, provided they use appropriate PPE for contact precautions.
Question 6: The emergency department charge nurse must prioritize four patients arriving simultaneously. Which patient is triaged as emergent (highest priority)?
- A 45-year-old with a laceration requiring sutures and stable vital signs
- A 60-year-old with diaphoresis, jaw pain, and a blood pressure of 90/60 mmHg (Correct answer)
- A 25-year-old with a sprained ankle, pain rated 6/10
- A 70-year-old with a urinary tract infection and low-grade fever
Correct answer: A 60-year-old with diaphoresis, jaw pain, and a blood pressure of 90/60 mmHg
Diaphoresis, jaw pain, and hypotension are classic signs of acute myocardial infarction with hemodynamic compromise, requiring immediate intervention.
Question 7: A nurse is delegating to a UAP on a busy medical-surgical unit. Which statement best reflects appropriate direction?
- 'Do whatever needs to be done for my patients while I attend to a critical situation.'
- 'Please take vital signs on Mr. Jones in room 204 every 4 hours and report to me immediately if his systolic BP drops below 100.' (Correct answer)
- 'You know what to do — I trust your judgment completely.'
- 'Help out wherever you think you are needed on the unit.'
Correct answer: 'Please take vital signs on Mr. Jones in room 204 every 4 hours and report to me immediately if his systolic BP drops below 100.'
Clear, specific direction with defined parameters and reporting criteria is essential for safe delegation to UAP.
BSN Prioritization, Delegation, and Assignment 3
A nurse receives a telephone order from a physician.
Which is the BEST action to ensure accuracy?