NURSING LEADERSHIP: PRIORITY AND DELEGATION EXAM
WITH WELL DETAILED QUESTION & ANSWERS PERFECTLY A+
GRADED WITH RATIONALE
A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and
possible pneumonia. Which nursing activity is most important to include in the patient's care?
A. Perform postural drainage and chest physiotherapy every 4 hours
B. Allow the patient to decide whether she needs aerosolized medications
C. Place the patient in a private room to decrease the risk of further infection
D. Plan activities to allow at least 8 hours of uninterrupted sleep CORRECT
ANSWER>>>>A. Perform postural drainage and chest physiotherapy every 4 hours
Airway clearance techniques are critical for patients with cystic fibrosis and should take priority
over the other activities. Although allowing more independent decision making is important for
adolescents, the physiologic need for improved respiratory function takes precedence at this
time. A private room may be desirable for the patient but is not necessary. With increased
shortness of breath, it will be more important that the patient have frequent respiratory
treatments than 8 hours of sleep.
A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What
instructions would you give the nursing assistant who will help the patient with activities of
daily living? Select all that apply.
A. Use a lift sheet when moving and positioning the patient in bed
B. Use an electric razor when shaving the patient each day
,C. Use a soft-bristled toothbrush or tooth sponge for oral care
D. Use a rectal thermometer to obtain a more accurate body temperature
E. Be sure the patient's footwear has a firm sole when the patient ambulates CORRECT
ANSWER>>>>A.B.C.E. While a patient is receiving anticoagulation therapy, it is important to
avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers
and enemas). All of the other instructions are appropriate to the care of a patient receiving
anticoagulants.
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a
nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the
nurse responsible for this patient's care, you would anticipate a physician order for what action?
A. Perform endotracheal intubation and initiate mechanical ventilation
B. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and
mouth
C. Administer furosemide (Lasix) 100 mg IV push stat
D. Call a code for respiratory arrest CORRECT ANSWER>>>>A. Perform endotracheal
intubation and initiate mechanical ventalation.
A non-rebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status
does not improve adequately in response to delivery of oxygen at this high concentration,
refractory hypoxemia is present. Usually at this stage, the patient is working very hard to
breathe and may go into respiratory arrest unless health care providers intervene by providing
intubation and mechanical ventilation to decrease the patient's work of breathing.
A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway
management should you delegate to a nursing assistant (PCT)?
A. Assisting the patient to sit up on the side of the bed
B. Instructing the patient to cough effectively
C. Teaching the patient to use incentive spirometry
,D. Auscultation of breath sounds every 4 hours CORRECT ANSWER>>>>A. Assisting the
patient to sit up on the side of the bed.
Assisting patients with positioning and activities of daily living is within the educational
preparation and scope of practice of a nursing assistant. Teaching, instructing, and assessing
patients all require additional education and skills and are more appropriate for a licensed
nurse.
A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted
sleep cycle. Which action should you delegate to the nursing assistant (PCT)?
A. Discuss weight-loss strategies such as diet and exercise with the patient
B. Teach the patient how to set up the BiPAP machine before sleeping
C. Remind the patient to sleep on his side instead of his back
D. Administer modafinil (Provigil) to promote daytime wakefulness CORRECT
ANSWER>>>>C. Remind the patient to sleep on his side instead of his back
The nursing assistant can remind patients about actions that have already been taught by the
nurse and are part of the patient's plan of care. Discussing and teaching require additional
education and training. These actions are within the scope of practice of the RN. The RN can
delegate administration of medication to an LPN/LVN.
After change of shift, you are assigned to care for the following patients. Which patient should
you assess first?
A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the
lab
, B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90%
saturation
C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics
D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator
CORRECT ANSWER>>>>D. A 50-year old with asthma who complains of shortness of breath
after using a bronchodilator
The patient with asthma did not achieve relief from shortness of breath after using the
bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. The
other patients need to be assessed as soon as possible, but none of their situations are urgent.
in COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable.
After the respiratory therapist performs suctioning on a patient who is intubated, the nursing
assistant measures vital signs for the patient. Which vital sign value should the nursing assistant
report to the RN immediately?
A. Heart rate of 98 beats/min
B. Respiratory rate of 24 breaths/min
C. Blood pressure of 168/90 mm Hg
D. Tympanic temperature of 101.4 F (38.6 C) CORRECT ANSWER>>>>D. Tympanic
temperature of 101.4 F (38.6 C)
Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal
tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for
bacteria or viruses to the lower part of the respiratory system.
An experienced LPN, under the supervision of the team leader RN, is providing nursing care for
a patient with a respiratory problem. Which actions are appropriate to the scope of practice of
an experienced LPN? Select all that apply.
A. Auscultate breath sounds
B. Administer medications via metered-dose inhaler (MDI)
C. Complete in-depth admission assessment
WITH WELL DETAILED QUESTION & ANSWERS PERFECTLY A+
GRADED WITH RATIONALE
A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and
possible pneumonia. Which nursing activity is most important to include in the patient's care?
A. Perform postural drainage and chest physiotherapy every 4 hours
B. Allow the patient to decide whether she needs aerosolized medications
C. Place the patient in a private room to decrease the risk of further infection
D. Plan activities to allow at least 8 hours of uninterrupted sleep CORRECT
ANSWER>>>>A. Perform postural drainage and chest physiotherapy every 4 hours
Airway clearance techniques are critical for patients with cystic fibrosis and should take priority
over the other activities. Although allowing more independent decision making is important for
adolescents, the physiologic need for improved respiratory function takes precedence at this
time. A private room may be desirable for the patient but is not necessary. With increased
shortness of breath, it will be more important that the patient have frequent respiratory
treatments than 8 hours of sleep.
A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What
instructions would you give the nursing assistant who will help the patient with activities of
daily living? Select all that apply.
A. Use a lift sheet when moving and positioning the patient in bed
B. Use an electric razor when shaving the patient each day
,C. Use a soft-bristled toothbrush or tooth sponge for oral care
D. Use a rectal thermometer to obtain a more accurate body temperature
E. Be sure the patient's footwear has a firm sole when the patient ambulates CORRECT
ANSWER>>>>A.B.C.E. While a patient is receiving anticoagulation therapy, it is important to
avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers
and enemas). All of the other instructions are appropriate to the care of a patient receiving
anticoagulants.
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a
nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the
nurse responsible for this patient's care, you would anticipate a physician order for what action?
A. Perform endotracheal intubation and initiate mechanical ventilation
B. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and
mouth
C. Administer furosemide (Lasix) 100 mg IV push stat
D. Call a code for respiratory arrest CORRECT ANSWER>>>>A. Perform endotracheal
intubation and initiate mechanical ventalation.
A non-rebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status
does not improve adequately in response to delivery of oxygen at this high concentration,
refractory hypoxemia is present. Usually at this stage, the patient is working very hard to
breathe and may go into respiratory arrest unless health care providers intervene by providing
intubation and mechanical ventilation to decrease the patient's work of breathing.
A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway
management should you delegate to a nursing assistant (PCT)?
A. Assisting the patient to sit up on the side of the bed
B. Instructing the patient to cough effectively
C. Teaching the patient to use incentive spirometry
,D. Auscultation of breath sounds every 4 hours CORRECT ANSWER>>>>A. Assisting the
patient to sit up on the side of the bed.
Assisting patients with positioning and activities of daily living is within the educational
preparation and scope of practice of a nursing assistant. Teaching, instructing, and assessing
patients all require additional education and skills and are more appropriate for a licensed
nurse.
A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted
sleep cycle. Which action should you delegate to the nursing assistant (PCT)?
A. Discuss weight-loss strategies such as diet and exercise with the patient
B. Teach the patient how to set up the BiPAP machine before sleeping
C. Remind the patient to sleep on his side instead of his back
D. Administer modafinil (Provigil) to promote daytime wakefulness CORRECT
ANSWER>>>>C. Remind the patient to sleep on his side instead of his back
The nursing assistant can remind patients about actions that have already been taught by the
nurse and are part of the patient's plan of care. Discussing and teaching require additional
education and training. These actions are within the scope of practice of the RN. The RN can
delegate administration of medication to an LPN/LVN.
After change of shift, you are assigned to care for the following patients. Which patient should
you assess first?
A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the
lab
, B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90%
saturation
C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics
D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator
CORRECT ANSWER>>>>D. A 50-year old with asthma who complains of shortness of breath
after using a bronchodilator
The patient with asthma did not achieve relief from shortness of breath after using the
bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. The
other patients need to be assessed as soon as possible, but none of their situations are urgent.
in COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable.
After the respiratory therapist performs suctioning on a patient who is intubated, the nursing
assistant measures vital signs for the patient. Which vital sign value should the nursing assistant
report to the RN immediately?
A. Heart rate of 98 beats/min
B. Respiratory rate of 24 breaths/min
C. Blood pressure of 168/90 mm Hg
D. Tympanic temperature of 101.4 F (38.6 C) CORRECT ANSWER>>>>D. Tympanic
temperature of 101.4 F (38.6 C)
Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal
tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for
bacteria or viruses to the lower part of the respiratory system.
An experienced LPN, under the supervision of the team leader RN, is providing nursing care for
a patient with a respiratory problem. Which actions are appropriate to the scope of practice of
an experienced LPN? Select all that apply.
A. Auscultate breath sounds
B. Administer medications via metered-dose inhaler (MDI)
C. Complete in-depth admission assessment
