Nursing Prioritization, Delegation and Assignment Flashcards

You are supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would you clearly instruct the nursing student to notify you about immediately?

Answer: Continuous bubbling in the water seal chamber

Continuous bubbling in the water seal chamber, after the initial post-insertion period, indicates an air leak within the chest tube system. This is a critical finding that requires immediate investigation and intervention, as it can prevent lung re-expansion and potentially lead to a tension pneumothorax. The nursing student must notify the RN immediately to address this serious complication.

You are supervising a student nurse who is performing tracheostomy care for a patient. For which action by the student should you intervene?

Answer: Removing the inner cannula and cleaning using universal precautions

The nurse should intervene if the student is removing the inner cannula and cleaning it using only "universal precautions." While universal precautions are always necessary, cleaning a reusable inner cannula requires sterile technique to prevent infection. If it's a disposable inner cannula, it should be replaced with a new sterile one, not cleaned. Therefore, the action described is either insufficient or incorrect for proper tracheostomy care.

You are supervising an RN who was pulled from the medical-surgical floor to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which of these directions would you clearly proved to the RN? (Select all that apply)

Answer: Apply direct lateral pressure to the nose for 5 minutes

When managing anterior epistaxis, several interventions are crucial. The nurse should instruct the patient to apply direct lateral pressure to the nose for at least 5 minutes to help stop the bleeding. Maintaining universal body substance precautions is essential due to contact with blood. Applying ice or cool compresses to the nose can promote vasoconstriction and reduce bleeding. Finally, instructing the patient not to blow their nose for several hours prevents dislodging clots and reinitiating bleeding.

You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately?

Answer: Marking the tube 1 cm from where it touches the incisor tooth or nares

The nurse must intervene immediately if the student marks the endotracheal tube 1 cm from where it touches the incisor tooth or nares. After intubation, the tube should be secured at the appropriate depth, and the measurement at the incisor or nares should be noted and documented to monitor for displacement. Marking it 1 cm away is not a standard practice and could lead to incorrect depth assessment or accidental dislodgement, compromising the patient's airway.

You have just finished assisting the physician with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is important to report to the physician?

Answer: The patient’s blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min

The patient's blood pressure of 100/48 mm Hg and heart rate of 102 beats/min after removing 1800 mL of fluid is the most important finding to report. This indicates potential hypovolemia or a significant vasovagal response due to the rapid fluid shift, which can lead to hemodynamic instability and shock. This physiological change requires immediate medical evaluation and intervention to prevent further complications.

You have obtained the following assessment information about a 3-year old who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow-up?

Answer: Frequent swallowing

Frequent swallowing after a tonsillectomy is the most critical finding and requires immediate follow-up. This is a classic sign of post-operative hemorrhage, as the patient is likely swallowing blood. Bleeding can lead to airway obstruction or significant blood loss, making it a life-threatening complication that demands urgent medical attention.

You are acting as preceptor for a newly graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide care to which patients? Select all that apply.

Answer: A 63-year old with a tracheostomy needing tracheostomy care every shift.

A newly graduated RN in their second week of orientation should be assigned patients with stable, predictable conditions that allow them to practice fundamental nursing skills under supervision. A 63-year-old with a tracheostomy needing routine tracheostomy care every shift fits this criterion, as it is a common procedure with established protocols. The other patients present with new diagnoses, recent major surgery, or potentially unstable conditions, which are more complex and require a more experienced RN.

A patient who is getting oxygen through a nasal cannula at a flow rate of 6 L/min complains of nasal passage irritation, the nursing assistant informs you. What course of action might you recommend to enhance the patient's comfort in light of this issue?

Answer: Suggest that the patient's oxygen be humidified

Oxygen delivered via nasal cannula, particularly at higher flow rates such as 6 L/min, can be very drying to the mucous membranes of the nasal passages, leading to irritation and discomfort. Humidifying the oxygen adds moisture, which helps prevent this dryness and significantly enhances patient comfort. This is a standard intervention for patients receiving oxygen therapy.

The following notation is made by the nurse on the patient's care plan: "Not achieved. Patient says, "I'm frightened of falling," and refuses to walk." The nurse needs to:

Answer: modify the care plan in response to the patient's condition and wishes.

The nursing process is dynamic and patient-centered, requiring continuous reassessment and adaptation. When a patient expresses fear or unwillingness to participate in a goal, the nurse must modify the care plan to address these concerns. Ignoring the patient's wishes or continuing with an unachievable plan is not effective; instead, the nurse should identify the underlying reason (fear of falling) and adjust interventions to ensure patient safety and promote cooperation.

A 22-year-old patient who underwent emergency surgery and many transfusions three days prior is examined, and you discover that the patient appears agitated and is breathing laboriously at a rate of 38 breaths per minute. 90% oxygen saturation is achieved with a 6 L/min nasal cannula oxygen supply. Which course of action is best?

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

The patient's agitation, tachypnea (38 breaths/min), and hypoxemia (SpO2 90% on 6 L/min nasal cannula) indicate acute respiratory distress and potential respiratory failure. Switching to a nonrebreather mask delivers the highest possible oxygen concentration, which is crucial for improving oxygenation in this critical situation. Simultaneously, the physician must be notified immediately to discuss the patient's deteriorating status and obtain further orders for definitive treatment.

The nursing care plan for a patient includes the sentences below. Which of the following sentences best describes a goal and an outcome?

Answer: The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by October 20, 2018, 1500.

A well-written nursing goal and outcome statement must be SMART: Specific, Measurable, Achievable, Relevant, and Time-bound. Option B clearly defines what the patient will achieve ("verbalize a decreased pain level"), how it will be measured ("less than 3 on a 0 to 10 scale"), and provides a specific timeframe for achievement ("by October 20, 2018, 1500"). This comprehensive detail makes it the best example of a goal and outcome.