Management of Care

Prior to inserting an intravenous catheter, the nurse tells the patient, “I promise this won’t hurt a bit.” Which ethical principle does the nurse risk breaking with this statement?

The bedside nurse delegates vital signs checks to an unlicensed assistive personnel (UAP) every four hours. Prior to the 1200 vital sign check, the UAP has a family emergency and leaves the unit without informing the nurse. As a result, the 1200 vitals are not completed. Who is responsible for this lapse in care?

The bedside nurse asks the unlicensed assistive personnel (UAP) to administer a tube feeding to a patient with a nasogastric tube. The UAP has never performed this task. Which action by the UAP is most appropriate?

Which aspect of delegation is the most crucial to ensure patient safety?

The unlicensed assistive personnel (UAP) performs a delegated task after failing to complete the yearly mandatory education and skills check-off and an adverse event occurs. Who is most responsible for the adverse event?

The bedside nurse asks the unlicensed assistive personnel (UAP) to help a stable patient to the bedside commode. Upon standing, the patient complains of being dizzy and lightheaded, but insists on using the commode. The UAP calls out to the bedside nurse for help, but the nurse had left the floor with another patient. The patient falls and sustains a mild head injury. Which individual is most responsible for the patient’s injury?

Which assessment does the nurse perform first in the unresponsive patient?

Which order does the nurse complete first in the patient with acute respiratory failure?

The nurse is assigned to a 32-year-old male admitted with bowel obstruction status post exploratory laparotomy. Which telephone call from the nurse to the provider is most appropriate?

The nurse calls the provider with this report: “Hi, Dr. Smith, the patient Mrs. Welch is complaining of an 8/10 pain in her lower abdomen. Her abdomen is distended but is soft with positive bowel sounds in all four quadrants. I have tried ambulation, warm compresses, and position changes, to no avail. Could you please come assess her?” Which component of SBAR communication does the nurse need to elaborate for this patient?

The nurse is assigned to care for several patients in the NICU. The nurse calls the advanced practice nurse about one of the patients and says, “Hello, this is Kelly Smith, a nurse working in the NICU. Can you please come assess the patient, Michael Doh, in bed 552? I’m concerned about him. Thanks!” Which component(s) of the SBAR communication does the nurse need to elaborate? Select all that apply.

The nurse is assigned several patients on the surgical floor. He calls the provider and says, “Hi there, the post-op day 1 in bed 14 asked me to call and request an order for increased dosage of his IV pain medication. His blood pressure has been consistently elevated and he has been tachycardic for the last 3 hours. Would you consider adding an adjuvant pain control medication?” Which aspect of this SBAR communication is most appropriate?

An unconscious patient presents to the emergency department following a benzodiazepine overdose and is noted to have the words, “Do Not Resuscitate,” tattooed across the chest. Which action by the medical team is most appropriate?

A terminally ill patient has attempted to commit suicide by swallowing an entire bottle of opioid pain medication.The patient is brought to the emergency department and found to have a “Do Not Resuscitate” tattoo on her chest along with a handwritten note that states that she is tired of suffering and wishes her life to end. Which next step by the medical team is most appropriate?

The nurse is assigned to care for a 45-year-old G2P1 female at 35 weeks estimated gestational age who is admitted with preeclampsia. On morning rounds, the patient says she is having considerable abdominal pain, so the provider writes multiple medication orders for her. Which medication order can the nurse carry out without clarification?

The nurse is assigned to care for a 14-year-old male who has repeatedly ripped out his IV line and attempted to harm himself with various objects found in the room despite a family member sitting at his bedside around the clock. He is placed in wrist restraints that are secured to the bed per physician order. If the current order was written at 1030, at what time that same day does the order expire?

The nurse would like to institute a process improvement project to improve the cleanliness of the patient rooms. Which key stakeholders does the nurse include? Select all that apply.

The nurse is making assignments for the oncoming shift in a stepdown unit. Which staff member is most appropriate to be assigned to the 74-year-old patient who has had a 3 year old tracheostomy connected to humidified oxygen, continuous gastrostomy feedings, and a peripherally-inserted central catheter for IV antibiotics who requires total care and turning every 2 hours?

Prior to transporting a patient to surgery, the nurse ensures which items are in the patient's chart? Select all that apply. 

Upon arrival of the patient to the post-anesthesia recovery unit (PACU), which assessment does the nurse perform first?

The patient who is scheduled for an elective surgery in 2 hours asks the nurse, “What time do the maids typically come to clean the hotel room?” Further questioning reveals the patient believes the hospital in the United States is a hotel in Paris, France, and the year is 20 years prior. The nurse notes that the patient signed a consent form for the procedure just minutes ago. Which action does the nurse take first?

The adult patient with type 1 diabetes mellitus and Parkinson’s disease lives alone. Which patient statement would prompt the nurse to advocate for a delay in discharge from the hospital?

Which statement by the novice nurse requires correction by the charge nurse?

Which patient must be treated first in the emergency department following a mass shooting?

Which process improvement project will be most effective in improving patient satisfaction?

Which observation prompts the nurse manager to implement a process improvement project on alarm fatigue in the unit?

Which situation in the hospital unit requires the most immediate attention?

Which patient is appropriate to assign to a licensed practical/vocational nurse (LPN/LVN)?

Which task in the care of a patient newly diagnosed with diabetes is appropriate to delegate to an unlicensed assistive personnel?

The nurse is caring for the patient who was admitted to the hospital after a fall at the nursing home. Which intervention does the nurse implement in order to reduce the patient’s fall risk?

Which assessment at the beginning of the shift of the patient with a recent head injury requires the most immediate action?

The patient is rushed into the emergency department by a family member who states the patient is having a stroke. Which action does the nurse take first?

After receiving report, which patient does the nurse see first?

Following a motor vehicle accident, the patient is unable to make his wishes known and is close to death without immediate and extensive treatment. The patient’s girlfriend, who he has been living with for the last five years, wants the medical team to do everything possible to save him. The patient’s wife, who he left when he moved in with his girlfriend, states she would not like any lifesaving measures and will sign the Do-Not-Resuscitate (DNR) paperwork. The medical team looks to which entity for decision-making?

The registered nurse asks the unlicensed assistive personnel to obtain the patient’s vital signs and to assist the patient to ambulate in the hallway. Which term is used to describe this nursing function?

Place the nursing interventions for a 16-year-old patient in the hospital for severe malnutrition and depression with a history of falls in order from highest priority to lowest priority.

Which nursing intervention is the highest priority for the patient admitted with a chronic obstructive pulmonary disease (COPD) exacerbation?

The patient is brought to the emergency department following a serious motor vehicular accident (MVA). List the assessments the nurse performs in order from highest to lowest priority.

The emergency department nurse is assessing the unconscious patient following a fall from the ladder while he was doing home improvement work. Which assessment is performed first?

The nurse is the first responder to a motor vehicular accident involving the injury of a 40-year-old male. Which action is the highest priority?

The nurse is involved in a motor vehicular accident in which a minor injury from the seatbelt was sustained. Which action does the nurse take first in helping the other victims?

A local celebrity is admitted to hospital following rupture of the appendix. The charge nurse submits an incident report if which individual accesses the patient’s chart?

The nurse learns that a fellow nurse is viewing the electronic chart of a patient with whom she went to high school. Which action does the nurse take first?

The grandparents of a baby in the newborn intensive care unit (NICU) ask the nurse about the age of another baby. Which response by the nurse is most appropriate?

The nurse delegates a pre-prandial blood sugar check to the unlicensed assistive personnel who fails to perform it before the patient’s food tray arrives and the patient eats breakfast. Who is most at fault?

As instructed by the registered nurse, the unlicensed assistive personnel (UAP) obtained vitals on a patient. The UAP obtained and charted the following vital signs monitoring results: blood pressure 90/42 mm Hg, pulse 128 bpm, oxygen saturation 86% on room air, and temperature 38.2°C. (100.8°F). The UAP left the floor for a break after charting the results, but did not tell the nurse. Thirty minutes later the patient is found unresponsive and a code blue is initiated. Who is responsible for this patient’s deterioration of condition?

Which task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

The patient from India tells the nurse that, in addition to his conventional medical treatment, he would also like to be treated according to the principles of Ayurvedic medicine. The nurse plans care based on which understanding of the focus of Ayurvedic medicine?

The nurse is assigned to care for a patient who speaks minimal English but is fluent in Farsi. Which is the best practice for the nurse to take when communicating with this patient?

The nurse is providing discharge instructions and education to a patient with stomach cancer who is interested in alternative/complementary medicine. Which low-risk therapies does the nurse include in the discussion? Select all that apply.