CHAPTER 21 - PRIORITIZATION, DELEGATION, AND ASSIGNMENT
Questions with Correct Solutions
Question:
1. A client presents to triage with fever, myalgia, severe headache, abdominal pain, vomiting,
diarrhea, and unexplained bruising that started after returning from Africa. The triage nurse
suspects, but is unsure, that the client may have Ebola. What should the nurse do *first*?
•Delay any additional assessment or questioning and don full personal protective equipment
•Isolate the client in a private room and initiate standard, contact, and droplet precautions
•Direct all clients and staff out of the triage area and call the infection control department
•Continue assessment and questioning to determine the likelihood of exposure to Ebola
Answer:
•Isolate the client in a private room and initiate standard, contact, and droplet precautions
•First, the nurse would isolate the client and initiate standard, contact, and droplet
precautions. The person can be taken out of isolation at any time if the health care provider
(HCP) determines that the client does not have Ebola, but in the meantime, isolation
precautions protect others. After the client is in isolation, the nurse's next actions are based
on the acuity of the client. If the client needs immediate assistance, the nurse would alert the
HCP and charge nurse. Selected team members would don personal protective equipment,
and care would be initiated. The infection control department should be notified as soon as
possible so that system-wide measures can be activated as needed.
Question:
2. An emergency department clinical nurse specialist is training staff in how to don and doff
personal protective equipment (PPE) when caring for clients with infections, such as Ebola.
Which staff member has demonstrated the *most* grievous error during the practice session?
•Triage nurse forgets to perform hand hygiene before donning PPE
•Unlicensed assistive personnel performs self-inspection; then begins to doff PPE
•Health care provider forgets to wipe shoes with disinfectant after doffing shoe covers
•Emergency medical technician doffs both pairs of gloves first
,Answer:
•Emergency medical technician doffs both pairs of gloves first
•All team members have made errors, but removing both pairs of gloves puts the emergency
medical technician at the greatest risk because the outer surfaces of the remaining PPE are
considered contaminated. According to the latest recommendations from the Centers for
Disease Control and Prevention, the flow of donning is as follows: hand hygiene, inner gloves,
shoe covers, gown, N95 respirator, hood, outer gloves, face shield, inspection (by self and
trained observer), range of motion, and hand hygiene. The flow of doffing is inspection (by
self and trained observer), hand hygiene, remove shoe covers, remove outer gloves, inspect
inner gloves, remove face shield, hand hygiene, remove hood, hand hygiene, remove gown,
hand hygiene, remove inner gloves, hand hygiene, apply new gloves, remove n95 respirator,
hand hygiene, disinfect shoes, hand hygiene, remove gloves, hand hygiene, and inspection (by
self and trained observer).
Question:
3. The charge nurse in an emergency department (ED) and must assign two staff members to
cover the triage area. Which team is the *most* appropriate for this assignment?
•An advanced practice nurse and an experienced RN
•An experienced LPN/LVN and an inexperienced RN
•An experienced RN and an inexperienced RN
•An experienced RN and an experienced unlicensed assistive personnel (UAP)
Answer:
•An advanced practice nurse and an experienced RN
•Triage requires at least one experienced RN. Advanced practice nurses can perform medical
screening exams, and this expedites treatment and decreases overall time spent in the ED.
Pairing an experienced RN with an inexperienced RN provides opportunities for mentoring.
This would be the second-best choice. Pairing an experienced RN with an experienced UAP is
an option if licensed staff is unavailable because the UAP can measure vital signs and assist in
transporting. An LPN/LVN is not qualified to perform the initial client assessment or decision
making, and the expertise of the LPN/LVN could be used elsewhere in a busy ED.
Question:
4. The nurse is working in the triage area of an emergency department, and the following four
clients approach the triage desk at the same time. List the order in which the nurse will
assess these clients.
•An ambulatory, dazed 25-year-old man with a bandaged head wound
•An irritable newborn with a fever, petechiae, and nuchal rigidity
•A 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity
•A 50-year-old woman with moderate abdominal pain and occasional vomiting
, Answer:
•An irritable newborn with a fever, petechiae, and nuchal rigidity
•An ambulatory, dazed 25-year-old man with a bandaged head wound
•A 50-year-old woman with moderate abdominal pain and occasional vomiting
•A 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity
•An irritable newborn with fever and petechiae should be further assessed for other signs of
meningitis. The client with the head wound needs additional assessment because of the risk
for increased intracranial pressure. The client with moderate abdominal pain is in discomfort,
but her condition is not unstable at this point. For the ankle injury, medical evaluation could
be delayed for 24 to 48 hours if necessary, but the client should receive the appropriate first
aid.
Question:
5. When a primary survey of a trauma client is conducted, what is one of the *priority* actions
that would be performed *first*?
•Obtain a complete set of vital sign measurements
•Palpate and auscultate the abdomen
•Perform a brief neurologic assessment
•Check the pulse oximetry reading
Answer:
•Perform a brief neurologic assessment
•A brief neurologic assessment to determine level of consciousness and pupil reaction is part
of the primary survey. Measuring vital signs, assessing the abdomen, and checking pulse
oximetry readings are considered part of the secondary survey.
Question:
6. A 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and
dizziness. What is the *priority* action?
•Initiate continuous electrocardiographic monitoring
•Notify the emergency department health care provider
•Administer oxygen via nasal cannula
•Draw blood and establish IV access
Answer:
•Administer oxygen via nasal cannula
•The priority goal is to increase myocardial oxygenation. The other actions are also
appropriate and should be performed immediately after administering oxygen.
Questions with Correct Solutions
Question:
1. A client presents to triage with fever, myalgia, severe headache, abdominal pain, vomiting,
diarrhea, and unexplained bruising that started after returning from Africa. The triage nurse
suspects, but is unsure, that the client may have Ebola. What should the nurse do *first*?
•Delay any additional assessment or questioning and don full personal protective equipment
•Isolate the client in a private room and initiate standard, contact, and droplet precautions
•Direct all clients and staff out of the triage area and call the infection control department
•Continue assessment and questioning to determine the likelihood of exposure to Ebola
Answer:
•Isolate the client in a private room and initiate standard, contact, and droplet precautions
•First, the nurse would isolate the client and initiate standard, contact, and droplet
precautions. The person can be taken out of isolation at any time if the health care provider
(HCP) determines that the client does not have Ebola, but in the meantime, isolation
precautions protect others. After the client is in isolation, the nurse's next actions are based
on the acuity of the client. If the client needs immediate assistance, the nurse would alert the
HCP and charge nurse. Selected team members would don personal protective equipment,
and care would be initiated. The infection control department should be notified as soon as
possible so that system-wide measures can be activated as needed.
Question:
2. An emergency department clinical nurse specialist is training staff in how to don and doff
personal protective equipment (PPE) when caring for clients with infections, such as Ebola.
Which staff member has demonstrated the *most* grievous error during the practice session?
•Triage nurse forgets to perform hand hygiene before donning PPE
•Unlicensed assistive personnel performs self-inspection; then begins to doff PPE
•Health care provider forgets to wipe shoes with disinfectant after doffing shoe covers
•Emergency medical technician doffs both pairs of gloves first
,Answer:
•Emergency medical technician doffs both pairs of gloves first
•All team members have made errors, but removing both pairs of gloves puts the emergency
medical technician at the greatest risk because the outer surfaces of the remaining PPE are
considered contaminated. According to the latest recommendations from the Centers for
Disease Control and Prevention, the flow of donning is as follows: hand hygiene, inner gloves,
shoe covers, gown, N95 respirator, hood, outer gloves, face shield, inspection (by self and
trained observer), range of motion, and hand hygiene. The flow of doffing is inspection (by
self and trained observer), hand hygiene, remove shoe covers, remove outer gloves, inspect
inner gloves, remove face shield, hand hygiene, remove hood, hand hygiene, remove gown,
hand hygiene, remove inner gloves, hand hygiene, apply new gloves, remove n95 respirator,
hand hygiene, disinfect shoes, hand hygiene, remove gloves, hand hygiene, and inspection (by
self and trained observer).
Question:
3. The charge nurse in an emergency department (ED) and must assign two staff members to
cover the triage area. Which team is the *most* appropriate for this assignment?
•An advanced practice nurse and an experienced RN
•An experienced LPN/LVN and an inexperienced RN
•An experienced RN and an inexperienced RN
•An experienced RN and an experienced unlicensed assistive personnel (UAP)
Answer:
•An advanced practice nurse and an experienced RN
•Triage requires at least one experienced RN. Advanced practice nurses can perform medical
screening exams, and this expedites treatment and decreases overall time spent in the ED.
Pairing an experienced RN with an inexperienced RN provides opportunities for mentoring.
This would be the second-best choice. Pairing an experienced RN with an experienced UAP is
an option if licensed staff is unavailable because the UAP can measure vital signs and assist in
transporting. An LPN/LVN is not qualified to perform the initial client assessment or decision
making, and the expertise of the LPN/LVN could be used elsewhere in a busy ED.
Question:
4. The nurse is working in the triage area of an emergency department, and the following four
clients approach the triage desk at the same time. List the order in which the nurse will
assess these clients.
•An ambulatory, dazed 25-year-old man with a bandaged head wound
•An irritable newborn with a fever, petechiae, and nuchal rigidity
•A 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity
•A 50-year-old woman with moderate abdominal pain and occasional vomiting
, Answer:
•An irritable newborn with a fever, petechiae, and nuchal rigidity
•An ambulatory, dazed 25-year-old man with a bandaged head wound
•A 50-year-old woman with moderate abdominal pain and occasional vomiting
•A 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity
•An irritable newborn with fever and petechiae should be further assessed for other signs of
meningitis. The client with the head wound needs additional assessment because of the risk
for increased intracranial pressure. The client with moderate abdominal pain is in discomfort,
but her condition is not unstable at this point. For the ankle injury, medical evaluation could
be delayed for 24 to 48 hours if necessary, but the client should receive the appropriate first
aid.
Question:
5. When a primary survey of a trauma client is conducted, what is one of the *priority* actions
that would be performed *first*?
•Obtain a complete set of vital sign measurements
•Palpate and auscultate the abdomen
•Perform a brief neurologic assessment
•Check the pulse oximetry reading
Answer:
•Perform a brief neurologic assessment
•A brief neurologic assessment to determine level of consciousness and pupil reaction is part
of the primary survey. Measuring vital signs, assessing the abdomen, and checking pulse
oximetry readings are considered part of the secondary survey.
Question:
6. A 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and
dizziness. What is the *priority* action?
•Initiate continuous electrocardiographic monitoring
•Notify the emergency department health care provider
•Administer oxygen via nasal cannula
•Draw blood and establish IV access
Answer:
•Administer oxygen via nasal cannula
•The priority goal is to increase myocardial oxygenation. The other actions are also
appropriate and should be performed immediately after administering oxygen.
