BSN Prioritization, Delegation, and Assignment 4 — Questions and Answers
Question 1: A nurse is evaluating a UAP's performance after delegating blood pressure monitoring. Which finding requires the nurse to re-educate the UAP?
- The UAP used the correct cuff size for the patient's arm
- The UAP reported a blood pressure of 90/58 mmHg to the nurse immediately
- The UAP independently decided to administer a PRN antihypertensive based on the reading (Correct answer)
- The UAP documented the blood pressure in the patient's electronic chart
Correct answer: The UAP independently decided to administer a PRN antihypertensive based on the reading
Administering medications — even PRN — is outside the UAP scope of practice; this decision and action belong exclusively to the licensed nurse.
Question 2: Which patient condition is an example of an 'urgent' priority (versus emergent or non-urgent) using triage principles?
- Complete airway obstruction
- A stable fracture with pain and swelling but intact circulation and sensation (Correct answer)
- Active arterial hemorrhage
- Cardiac arrest
Correct answer: A stable fracture with pain and swelling but intact circulation and sensation
A stable fracture with intact neurovascular status is urgent — it needs timely attention but is not immediately life-threatening like cardiac arrest or airway obstruction.
Question 3: A nurse is caring for postpartum patients. Which patient requires the nurse's most immediate assessment?
- A patient 6 hours post-vaginal delivery reporting mild uterine cramping while breastfeeding
- A patient 2 hours post-cesarean delivery with a blood pressure of 80/50 mmHg and heart rate of 120 bpm (Correct answer)
- A patient requesting additional ice packs for perineal discomfort
- A patient 12 hours postpartum asking questions about newborn care
Correct answer: A patient 2 hours post-cesarean delivery with a blood pressure of 80/50 mmHg and heart rate of 120 bpm
Hypotension and tachycardia at 2 hours post-cesarean indicate possible hemorrhage or other hemodynamic instability requiring immediate assessment.
Question 4: Which action demonstrates appropriate supervision after delegation?
- Telling the delegate to report back only if something goes wrong
- Checking in with the delegate mid-task and evaluating the patient's response after task completion (Correct answer)
- Assuming the task was done correctly because the delegate is experienced
- Delegating the supervisory responsibility to another UAP
Correct answer: Checking in with the delegate mid-task and evaluating the patient's response after task completion
Checking in during and after task completion ensures the task was performed safely and the patient's condition is as expected.
Question 5: A nurse manager notices consistent conflict between two staff RNs regarding patient assignments. What is the most appropriate first action?
- Separate the nurses by assigning them to different shifts immediately
- Meet with both nurses individually to understand each perspective before facilitating a joint resolution (Correct answer)
- Ignore the situation and wait to see if it resolves on its own
- Report both nurses to administration for disciplinary action
Correct answer: Meet with both nurses individually to understand each perspective before facilitating a joint resolution
Gathering each party's perspective individually is the first step in conflict resolution, allowing the manager to facilitate a fair, informed discussion.
Question 6: A nurse is using the CURE hierarchy when setting priorities. What does this model address that Maslow's hierarchy does not?
- Physical needs
- Psychosocial needs
- Time-sensitivity and acuity of clinical deterioration (Correct answer)
- Self-actualization
Correct answer: Time-sensitivity and acuity of clinical deterioration
The CURE model (Critical, Urgent, Routine, Extras) specifically incorporates clinical acuity and time-sensitivity, which Maslow's hierarchy does not directly address.
Question 7: A nurse receives report on four patients. Which patient should the nurse visit FIRST?
- A patient with type 2 diabetes whose blood glucose was 180 mg/dL at breakfast
- A patient who received morphine 30 minutes ago and now has a respiratory rate of 8 breaths/min (Correct answer)
- A patient with stable chronic heart failure awaiting discharge paperwork
- A patient post-op day 3 with a surgical site that is clean, dry, and intact
Correct answer: A patient who received morphine 30 minutes ago and now has a respiratory rate of 8 breaths/min
A respiratory rate of 8 breaths/min after opioid administration indicates respiratory depression, a life-threatening emergency requiring immediate intervention.
BSN Prioritization, Delegation, and Assignment 4
A nurse is evaluating a UAP's performance after delegating blood pressure monitoring.
Which finding requires the nurse to re-educate the UAP?