NURS 123Prioritization & Delegation Set 2 NURS 123Prioritization & Delegation Set 2
Prioritization & Delegation – Set 2
1. You are supervising a student nurse who is performing tracheostomy care for a client.
For which action should you intervene?
A. The student nurse suctions the tracheostomy tube prior to performing tracheostomy care.
B. The student nurse removes old dressings and cleans off excess secretions.
C. The student nurse removes the inner cannula and cleans using universal precautions.
D. The student nurse replaces the inner cannula and cleans the stoma site.
E. The student nurse changes the soiled tracheostomy ties and secures the tube in place.
2. You are evaluating and assessing a client diagnosed with chronic emphysema. The client
is on oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you
immediately?
A. The client has fine bibasilar crackles.
B. The client’s respiratory rate is 8 breaths/minute.
C. The client has a large barrel chest.
D. The client sits up and leans over the nightstand.
3. You are acting as a preceptor for a new graduate RN during her second week of
orientation. Which of the following client(s) would you assign the nursing care to the new
RN under your supervision? (Select all that apply.)
A. A 49-year-old new admission client with new diagnosis of esophageal cancer.
B. A 56-year-old client with lung cancer just returned from left lower lobectomy.
C. A 38-year-old client with moderate persistent asthma awaiting discharge.
D. A 63-year-old client with tracheostomy needing trach care every shift.
4. You are the team leader RN working with a student nurse. The student nurse is to teach
the client how to use a multidose inhaler without a spacer. Put the steps that the student
nurse should teach the client in the correct order.
A. Remove the inhaler cap and shake the inhaler.
B. Tilt your head back and breathe out fully.
C. Open your mouth and place the mouthpiece 1-2 inches away.
D. Hold your breath for at least 10 seconds.
E. Press down firmly on the canister and breathe deeply through your mouth.
F. Wait at least 1 minute between
puffs. Order: _A, b, c, e, d, f
5. Your client has chronic obstructive pulmonary disease (COPD). Which intervention
for airway management should you delegate to the nursing assistant?
A. Auscultate breath sounds every 4 hours.
B. Teach client how to use incentive spirometry.
C. Instruct client how to cough effectively.
This study source was downloaded by 100000832558064 from CourseHero.com on 03-28-2022 10:15:07 GMT -05:00
https://www.coursehero.com/file/16248521/Prioritization-Delegation-Set-2/
, NURS 123Prioritization & Delegation Set 2 NURS 123Prioritization & Delegation Set 2
D. Assist client to sit up on the side of the bed.
6. After change of shift, you are assigned to care for the following clients. Which client
should you assess first?
A. A 51-year-old client with asthma complaining of shortness of breath after using a
bronchodilator.
B. A 68-year-old client on ventilator who needs a sterile sputum specimen sent to the
laboratory.
C. A 57-year-old client with COPD and pulse oximetry reading from the previous shift of
90% saturation.
D. A 72-year-old client with pneumonia who needs to be started on intravenous antibiotics.
7. The client with pulmonary emboli (PE) is receiving anticoagulation with IV heparin. What
instructions will you give the nursing assistant who will assist the client with ADLs?
(Select all that apply.)
A. Use a lift sheet when moving and positioning the client.
B. Use an electric razor when shaving the client each day.
C. Use a soft-bristled toothbrush or tooth sponge for oral care.
D. Be sure the client’s footwear has firm soles for ambulation.
E. Use a rectal thermometer to attain a more accurate body temperature.
8. You are precepting an RN who is orienting to the intensive care unit (ICU). The RN
is providing care for a client with ARDS who has just been intubated in preparation
for mechanical ventilation. You observe the nurse perform all of these actions. For
which action must you intervene immediately?
A. The RN assesses the client for bilateral breath sounds and symmetrical chest movement.
B. The RN auscultates over the stomach to rule out esophageal intubation.
C. The RN marks the tube 1 cm from where it touches the incisor tooth or nares.
D. The RN orders a chest x-ray to verify the tube placement is correct.
9. You have just finished assisting the physician with a thoracentesis for a client with
recurrent left pleural effusion caused by lung cancer. The physician was able to remove
1800 mL of fluid during the thoracentesis. Which assessment information will be of most
concern?
A. The client’s dressing at the thoracentesis site has 1 cm of bloody drainage.
B. The client’s blood pressure is 100/48 and her pulse rate is 102 beats/minute.
C. The client says that she has sharp, stabbing chest pain every time she takes a deep breath.
D. The client cries and states that she cannot go on with treatment much longer.
10. A 24-year-old client with cystic fibrosis is admitted with increased shortness of breath and
possible pneumonia. Which nursing activity is most important to include in the client’s
care?
This study source was downloaded by 100000832558064 from CourseHero.com on 03-28-2022 10:15:07 GMT -05:00
https://www.coursehero.com/file/16248521/Prioritization-Delegation-Set-2/
Prioritization & Delegation – Set 2
1. You are supervising a student nurse who is performing tracheostomy care for a client.
For which action should you intervene?
A. The student nurse suctions the tracheostomy tube prior to performing tracheostomy care.
B. The student nurse removes old dressings and cleans off excess secretions.
C. The student nurse removes the inner cannula and cleans using universal precautions.
D. The student nurse replaces the inner cannula and cleans the stoma site.
E. The student nurse changes the soiled tracheostomy ties and secures the tube in place.
2. You are evaluating and assessing a client diagnosed with chronic emphysema. The client
is on oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you
immediately?
A. The client has fine bibasilar crackles.
B. The client’s respiratory rate is 8 breaths/minute.
C. The client has a large barrel chest.
D. The client sits up and leans over the nightstand.
3. You are acting as a preceptor for a new graduate RN during her second week of
orientation. Which of the following client(s) would you assign the nursing care to the new
RN under your supervision? (Select all that apply.)
A. A 49-year-old new admission client with new diagnosis of esophageal cancer.
B. A 56-year-old client with lung cancer just returned from left lower lobectomy.
C. A 38-year-old client with moderate persistent asthma awaiting discharge.
D. A 63-year-old client with tracheostomy needing trach care every shift.
4. You are the team leader RN working with a student nurse. The student nurse is to teach
the client how to use a multidose inhaler without a spacer. Put the steps that the student
nurse should teach the client in the correct order.
A. Remove the inhaler cap and shake the inhaler.
B. Tilt your head back and breathe out fully.
C. Open your mouth and place the mouthpiece 1-2 inches away.
D. Hold your breath for at least 10 seconds.
E. Press down firmly on the canister and breathe deeply through your mouth.
F. Wait at least 1 minute between
puffs. Order: _A, b, c, e, d, f
5. Your client has chronic obstructive pulmonary disease (COPD). Which intervention
for airway management should you delegate to the nursing assistant?
A. Auscultate breath sounds every 4 hours.
B. Teach client how to use incentive spirometry.
C. Instruct client how to cough effectively.
This study source was downloaded by 100000832558064 from CourseHero.com on 03-28-2022 10:15:07 GMT -05:00
https://www.coursehero.com/file/16248521/Prioritization-Delegation-Set-2/
, NURS 123Prioritization & Delegation Set 2 NURS 123Prioritization & Delegation Set 2
D. Assist client to sit up on the side of the bed.
6. After change of shift, you are assigned to care for the following clients. Which client
should you assess first?
A. A 51-year-old client with asthma complaining of shortness of breath after using a
bronchodilator.
B. A 68-year-old client on ventilator who needs a sterile sputum specimen sent to the
laboratory.
C. A 57-year-old client with COPD and pulse oximetry reading from the previous shift of
90% saturation.
D. A 72-year-old client with pneumonia who needs to be started on intravenous antibiotics.
7. The client with pulmonary emboli (PE) is receiving anticoagulation with IV heparin. What
instructions will you give the nursing assistant who will assist the client with ADLs?
(Select all that apply.)
A. Use a lift sheet when moving and positioning the client.
B. Use an electric razor when shaving the client each day.
C. Use a soft-bristled toothbrush or tooth sponge for oral care.
D. Be sure the client’s footwear has firm soles for ambulation.
E. Use a rectal thermometer to attain a more accurate body temperature.
8. You are precepting an RN who is orienting to the intensive care unit (ICU). The RN
is providing care for a client with ARDS who has just been intubated in preparation
for mechanical ventilation. You observe the nurse perform all of these actions. For
which action must you intervene immediately?
A. The RN assesses the client for bilateral breath sounds and symmetrical chest movement.
B. The RN auscultates over the stomach to rule out esophageal intubation.
C. The RN marks the tube 1 cm from where it touches the incisor tooth or nares.
D. The RN orders a chest x-ray to verify the tube placement is correct.
9. You have just finished assisting the physician with a thoracentesis for a client with
recurrent left pleural effusion caused by lung cancer. The physician was able to remove
1800 mL of fluid during the thoracentesis. Which assessment information will be of most
concern?
A. The client’s dressing at the thoracentesis site has 1 cm of bloody drainage.
B. The client’s blood pressure is 100/48 and her pulse rate is 102 beats/minute.
C. The client says that she has sharp, stabbing chest pain every time she takes a deep breath.
D. The client cries and states that she cannot go on with treatment much longer.
10. A 24-year-old client with cystic fibrosis is admitted with increased shortness of breath and
possible pneumonia. Which nursing activity is most important to include in the client’s
care?
This study source was downloaded by 100000832558064 from CourseHero.com on 03-28-2022 10:15:07 GMT -05:00
https://www.coursehero.com/file/16248521/Prioritization-Delegation-Set-2/
