NCLEX Exam: Nursing Prioritization, Delegation and Assignment 3
You are admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient’s history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus?
Patients who have recently experienced trauma are at risk for deep vein thrombosis and pulmonary embolus. None of the other findings are risk factors for pulmonary embolus. Prolonged immobilization is also a risk factor for DVT and pulmonary embolus, but this period of bed rest was very short.
You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced nursing assistant?
The nursing assistant’s educational preparation includes measurement of vital signs, and an experienced nursing assistant would know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN
You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care?
Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP
You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you immediately?
For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This patient’s oxygen flow is too high and is causing a high serum oxygen level, which results in a decreased respiratory arrest. Crackles, barrel chest, and assumption of a sitting position leaning over the night table are common in patients with chronic emphysema
You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to a nursing assistant?
A nursing assistant can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic nursing assistant. However, an experienced nursing assistant could assist the patient with positioning after the nursing assistant and the patient had been taught the proper technique. The nursing assistant would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill, and is within the scope of practice of the RN
You are making a home visit to a 50-year old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism. The patient’s only medication is enoxaparin (Lovenox) subcutaneously. Which assessment information will you need to communicate to the physician?
Confusion in a patient this age is unusual and may be an indication of intracerebral bleeding associated with enoxaparin use. The right leg symptoms are consistent with a resolving deep vein thrombosis; the patient may need teaching about keeping the right leg elevated above the heart to reduce swelling and pain. The presence of ecchymoses may point to a need to do more patient teaching about avoiding injury while taking anticoagulants but does not indicate that the physician needs to be called.
You are providing care for a patient with recently diagnosed asthma. Which key points would you be sure to include in your teaching plan for this patient? (Select all that apply)
Please select 4 correct answers
Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma.
You are providing nursing care for a newborn infant with respiratory distress syndrome (RDS) who is receiving nasal CPAP ventilation. What complications should you monitor for this infant?
The most common complications after birth for infants with RDS is pneumothorax. Alveoli rupture and air leaks into the chest and compresses the lungs, which makes breathing difficult
You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given a nursing diagnosis of Activity Intolerance. Which action should you delegate to the nursing assistant?
The nursing assistant’s training includes how to monitor and record intake and output. After the nurse has taught the patient about the importance of adequate nutritional intake for energy, the nursing assistant can remind and encourage the patient to take in adequate nutrition. Instructing patients and planning activities require more education and skill, and are appropriate to the RN’s scope of practice. Monitoring the patient’s cardiovascular response to activity is a complex process requiring additional education, training, and skill, and falls within the RN’s scope of practice
With regard to their incapacity to understand spoken language, a patient with disturbed auditory perception is being cared for by a nurse. Which examination of the patient would reveal a coping mechanism for the sensory deficit?
The assessment of "Impaired Urinary Elimination" does not directly indicate an adaptation to the sensory deficit described in the nursing diagnosis of Disturbed Sensory Perception (auditory) related to the inability to discern spoken language.
Impaired Urinary Elimination refers to a disruption in the normal process of urination and is unrelated to sensory perception deficits. It typically involves difficulties in voiding, such as decreased urinary output, urinary retention, or urinary incontinence. Assessing for impaired urinary elimination would involve evaluating the patient's urinary patterns, symptoms, and any physical or physiological factors that may contribute to the problem.
A newly graduated nurse is having trouble setting priorities for care and finishing the shift on time. The nurse manager observes that after a recent event in which the new nurse assigned an improper assignment to a UAP, the new nurse rarely assigns duties to the unlicensed assistance persons (UAP). Which of the nurse manager's options would be the most effective in resolving this issue?
The best action by the nurse manager to address the situation would be to review state and facility guidelines concerning delegation with the nurse.
Delegation is an essential skill for nurses, and understanding the guidelines and regulations related to delegation is crucial to ensure safe and effective care delivery. By reviewing the state and facility guidelines with the new nurse, the nurse manager can help clarify and reinforce the appropriate delegation practices.
The patient assignment for today is being created by the nurse manager. Five nursing technicians (NAs), two licensed practical nurses (LPNs), and five registered nurses (RNs) are slated to work with her. The nurse manager needs to keep the following in mind when determining the assignment:
The statement "RNs are responsible for all care delegated to unlicensed nursing personnel" is not accurate. While registered nurses (RNs) have the authority to delegate tasks to unlicensed nursing personnel, they are not solely responsible for all care delegated to them.
Examples of: Repositioning a patient, giving cleanliness, and active listening
Repositioning a patient, providing hygiene, and active listening are actually examples of collaborative nursing interventions.
Collaborative nursing interventions are those activities that require the participation of multiple healthcare professionals to achieve desired patient outcomes. These interventions involve cooperation and coordination among members of the healthcare team, including nurses, physicians, physical therapists, occupational therapists, social workers, and others.
When a nurse walks into a room, the patient is sitting up in bed sobbing. How might the nurse approach this scenario with a critical thinking attitude?
In this situation, the nurse can display a critical thinking attitude by asking the patient why she is crying. This demonstrates an active and engaged approach to understanding the patient's emotions and gathering relevant information.
By asking the patient about the reason for crying, the nurse shows a willingness to explore the underlying cause of distress, rather than making assumptions or jumping to conclusions.
Advance orders for a patient who is expected to be admitted from the emergency room have been given to the nurse (ER). Herman Goldstein is the patient's name. The nurse switches the patient's diet from "Regular" to "Kosher" in an effort to do her job faster. The nurse learns that the patient is Catholic even though his father is Jewish when the patient arrives at the unit. The nurse is accountable for caving in to
The nurse is guilty of giving in to an erroneous assumption. The nurse assumed that the patient's religious dietary preference would align with his father's religion without verifying the information. This assumption led to an incorrect change in the patient's diet from "Regular" to "Kosher" based on inaccurate information.
A patient's pain history for the last three days is being reviewed by the nurse, who observes that the pain level has not changed. The nurse confirms the patient's level of pain before deciding to call the doctor for more instructions. The nurse is employing the following procedure in this case:
In this scenario, the nurse is using the process of judgment. Judgment refers to the ability to make decisions or form opinions based on available information and critical thinking.
The nurse reviews the patient's pain history and notes that the pain level has remained constant over the last three days. By validating the pain level with the patient, the nurse gathers additional information to ensure accuracy. Based on this assessment, the nurse exercises judgment and determines that further intervention is necessary.