NUR 115 FINAL EXAM QUESTIONS AND ANSWERS
Delegation - Answers - - transfer of responsibility or authority; gives a competent
individual the authority to perform a nursing task in a selected situation while the nurse
retains accountability for that action
First Principle of Delegation - Answers - nurses need to know the scope of their practice
Second Principle of Delegation - Answers - the nurse cannot delegate the nursing
process (adpie) or accountability
Third Principle of Delegation - Answers - the person whom a task was delegated to
cannot delegate that task to someone else and if the task cannot be completed, the
nurse needs to be notified so the task can be reassigned
Five Rights of Delegation - Answers - - right task, right circumstances, right person, right
direction of communication, right supervision
Assist the patient in getting cleaned up - Answers - A nurse delegates a bed bath to a
group of nursing students after morning report. After lunch, the patient rings the call bell
and angrily tells the nurse that he has not been cleaned up. What should the nurse's
next action be?
Communicating the work assignment in terms that are easy to understand - Answers -
The new nurse manager is delegating tasks to the staff. What is a requirement for the
nurse manager in the delegation process?
Administer oral care every 3-4 hours - Answers - The newly hired nurse is assigned by
the charge nurse to care for a patient with acute renal failure and hypernatremia. Which
action can the nurse assign to the nursing assistant? Select all that apply.
Prioritization - Answers - differentiating between problems that need immediate
attention and problems that can wait; determining what is most important
Prioritization Strategies - Answers - ABCs, Maslow's Hierarchy of Needs, ADPIE, Age,
Admission, Surgery, Body systems
Respiratory Rate of 8-10 breaths/minute - Answers - Two student nurses are assigned
to a patient with lung cancer who has received oxycodone (Roxicodone) 10 mg orally
for pain. During the assessment, which finding should the student nurses report
immediately?
A 50-year old with asthma who complains of shortness of breath after using a
bronchodilator - Answers - After a change of shift, you are assigned to care for the
following patients. Which patient should you assess first?
, A patient who had a total knee replacement two days ago and needs blood glucose
monitoring - Answers - Janna is a nurse from the medical-surgical unit of a community
hospital. She was asked to float on the orthopedic unit in which she has no prior
experience working on. Which patient should be assigned to her?
QSEN - Answers - Quality and Safety Education for Nurses; "helps to redesign the
'What' and 'How' they deliver nursing care"; unified high standard of nursing care with
specific competencies to ensure quality and safety standards are continuously improved
Six competencies of QSEN - Answers - Patient-centered care, teamwork and
collaboration, evidence-based practice, quality improvement, safety, and informatics
Vital signs - Answers - measure/monitor the functioning of body systems and allow
providers to detect changes in physiological well-being of patients and provide
qualitative care
Temperature - Answers - afebrile, febrile, hypothermic
Pulse - Answers - bradycardia, tachycardia, intensity, rate, and rhythm
Respirations - Answers - assess rate (tachypnea, eupnea, bradypnea), effort
(orthopnea, dyspnea, accessory muscles), hyperventilation and hypoventilation
Oxygen Saturation - Answers - a clinical measurement of the percentage of hemoglobin
that is bound with oxygen in the blood
Blood Pressure - Answers - systolic/diastolic, hypertension, hypotension
Factors that affect vital signs - Answers - age, activity, stress, smoking, diet, gender,
medications, fluid status, and disease process
Count the respirations - Answers - A postoperative patient is breathing rapidly. You
should immediately:
discourages the patient from drinking excess fluids - Answers - A student nurse taking
care of a patient with an abnormal body temperature needs more training when he/she
does what?
SBP 147 - Answers - An 82-year-old widower brought via ambulance is admitted to the
emergency department with complaints of shortness of breath, anorexia, and malaise.
He recently visited his health care provider and was put on an antibiotic for pneumonia.
The client indicates that he also takes a diuretic and a beta blocker, which helps his
"high blood." Which vital sign value would take priority in initiating care?
Delegation - Answers - - transfer of responsibility or authority; gives a competent
individual the authority to perform a nursing task in a selected situation while the nurse
retains accountability for that action
First Principle of Delegation - Answers - nurses need to know the scope of their practice
Second Principle of Delegation - Answers - the nurse cannot delegate the nursing
process (adpie) or accountability
Third Principle of Delegation - Answers - the person whom a task was delegated to
cannot delegate that task to someone else and if the task cannot be completed, the
nurse needs to be notified so the task can be reassigned
Five Rights of Delegation - Answers - - right task, right circumstances, right person, right
direction of communication, right supervision
Assist the patient in getting cleaned up - Answers - A nurse delegates a bed bath to a
group of nursing students after morning report. After lunch, the patient rings the call bell
and angrily tells the nurse that he has not been cleaned up. What should the nurse's
next action be?
Communicating the work assignment in terms that are easy to understand - Answers -
The new nurse manager is delegating tasks to the staff. What is a requirement for the
nurse manager in the delegation process?
Administer oral care every 3-4 hours - Answers - The newly hired nurse is assigned by
the charge nurse to care for a patient with acute renal failure and hypernatremia. Which
action can the nurse assign to the nursing assistant? Select all that apply.
Prioritization - Answers - differentiating between problems that need immediate
attention and problems that can wait; determining what is most important
Prioritization Strategies - Answers - ABCs, Maslow's Hierarchy of Needs, ADPIE, Age,
Admission, Surgery, Body systems
Respiratory Rate of 8-10 breaths/minute - Answers - Two student nurses are assigned
to a patient with lung cancer who has received oxycodone (Roxicodone) 10 mg orally
for pain. During the assessment, which finding should the student nurses report
immediately?
A 50-year old with asthma who complains of shortness of breath after using a
bronchodilator - Answers - After a change of shift, you are assigned to care for the
following patients. Which patient should you assess first?
, A patient who had a total knee replacement two days ago and needs blood glucose
monitoring - Answers - Janna is a nurse from the medical-surgical unit of a community
hospital. She was asked to float on the orthopedic unit in which she has no prior
experience working on. Which patient should be assigned to her?
QSEN - Answers - Quality and Safety Education for Nurses; "helps to redesign the
'What' and 'How' they deliver nursing care"; unified high standard of nursing care with
specific competencies to ensure quality and safety standards are continuously improved
Six competencies of QSEN - Answers - Patient-centered care, teamwork and
collaboration, evidence-based practice, quality improvement, safety, and informatics
Vital signs - Answers - measure/monitor the functioning of body systems and allow
providers to detect changes in physiological well-being of patients and provide
qualitative care
Temperature - Answers - afebrile, febrile, hypothermic
Pulse - Answers - bradycardia, tachycardia, intensity, rate, and rhythm
Respirations - Answers - assess rate (tachypnea, eupnea, bradypnea), effort
(orthopnea, dyspnea, accessory muscles), hyperventilation and hypoventilation
Oxygen Saturation - Answers - a clinical measurement of the percentage of hemoglobin
that is bound with oxygen in the blood
Blood Pressure - Answers - systolic/diastolic, hypertension, hypotension
Factors that affect vital signs - Answers - age, activity, stress, smoking, diet, gender,
medications, fluid status, and disease process
Count the respirations - Answers - A postoperative patient is breathing rapidly. You
should immediately:
discourages the patient from drinking excess fluids - Answers - A student nurse taking
care of a patient with an abnormal body temperature needs more training when he/she
does what?
SBP 147 - Answers - An 82-year-old widower brought via ambulance is admitted to the
emergency department with complaints of shortness of breath, anorexia, and malaise.
He recently visited his health care provider and was put on an antibiotic for pneumonia.
The client indicates that he also takes a diuretic and a beta blocker, which helps his
"high blood." Which vital sign value would take priority in initiating care?
